Provider Demographics
NPI:1902858533
Name:PRESCOTT CARDIOLOGY, PC
Entity Type:Organization
Organization Name:PRESCOTT CARDIOLOGY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:MR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:ROTHROCK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:928-776-0601
Mailing Address - Street 1:804 AINSWORTH DR
Mailing Address - Street 2:SUITE 102
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86301-1624
Mailing Address - Country:US
Mailing Address - Phone:928-776-0601
Mailing Address - Fax:928-776-0620
Practice Address - Street 1:804 AINSWORTH DR
Practice Address - Street 2:SUITE 102
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301-1624
Practice Address - Country:US
Practice Address - Phone:928-776-0601
Practice Address - Fax:928-776-0620
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-16
Last Update Date:2016-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ26235174400000X
207RS0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ438780Medicaid
AZZ109694Medicare PIN
AZC93665Medicare UPIN