Provider Demographics
NPI:1396919387
Name:YRMC PHYSICIANCARE INTERNAL MEDICINE
Entity type:Organization
Organization Name:YRMC PHYSICIANCARE INTERNAL MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:
Authorized Official - Last Name:BOLIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-771-5758
Mailing Address - Street 1:3120 CLEARWATER DR
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86305-7131
Mailing Address - Country:US
Mailing Address - Phone:928-771-3704
Mailing Address - Fax:
Practice Address - Street 1:3120 CLEARWATER DR
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86305-7131
Practice Address - Country:US
Practice Address - Phone:928-771-3704
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-22
Last Update Date:2010-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ35216261QP2400X, 261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No261QP2400XAmbulatory Health Care FacilitiesClinic/CenterPrison Health