Basic Information
| Provider Information | |||||||||
| NPI: | 1508865528 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TAHOE CARSON VALLEY MEDICAL GROUP INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1111 EMERALD BAY RD | ||||||||
| Address2: | |||||||||
| City: | SOUTH LAKE TAHOE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 961506207 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5305435659 | ||||||||
| FaxNumber: | 5305418723 | ||||||||
| Practice Location | |||||||||
| Address1: | 2170 SOUTH AVE | ||||||||
| Address2: | |||||||||
| City: | SOUTH LAKE TAHOE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 96150 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5305413420 | ||||||||
| FaxNumber: | 5305418723 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2005 | ||||||||
| LastUpdateDate: | 07/10/2018 | ||||||||
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| AuthorizedOfficialLastName: | JONES | ||||||||
| AuthorizedOfficialFirstName: | ERIN | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5305435660 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207RC0000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RR0500X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Rheumatology | 207V00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207Y00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology | 208000000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 2084P0800X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 208600000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | 208800000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology | 208M00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Hospitalist | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | GR0055020 | 05 | CA | MEDICAID | USA292960 | 01 | CA | BLUE SHIELD OF CA | OTHER | USA293170 | 01 | CA | BLUE SHIELD OF CA | OTHER | USA293250 | 01 | CA | BLUE SHIELD OF CA | OTHER | ZZZ65882Z | 01 | CA | BLUE SHIELD OF CA | OTHER | GR0055022 | 05 | CA | MEDICAID | USA292950 | 01 | CA | BLUE SHIELD OF CA | OTHER | XGG007610 | 05 | CA | MEDICAID | XGG007611 | 05 | CA | MEDICAID | ZZZ61294Z | 01 | CA | BLUE SHIELD OF CA | OTHER | GR0055021 | 05 | CA | MEDICAID | GR0055023 | 05 | CA | MEDICAID | ZZZ54133Z | 01 | CA | BLUE SHIELD OF CA | OTHER | USA292970 | 01 | CA | BLUE SHIELD OF CA | OTHER | 100506149 | 05 | NV | MEDICAID | 100506911 | 05 | CA | MEDICAID | XGG007612 | 05 | CA | MEDICAID | ZZZ14014Z | 01 | CA | BLUE SHIELD OF CA | OTHER |