Provider Demographics
NPI:1720110984
Name:PRESCOTT GASTROENTEROLOGY
Entity Type:Organization
Organization Name:PRESCOTT GASTROENTEROLOGY
Other - Org Name:PRESCOTT GASTROENTEROLOGY CONSULTANTS MEDICAL GROUP
Other - Org Type:Other Name
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEBBIE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:DE LUNA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-771-5548
Mailing Address - Street 1:811 AINSWORTH DR STE 103
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86301-1687
Mailing Address - Country:US
Mailing Address - Phone:928-771-5548
Mailing Address - Fax:928-771-5549
Practice Address - Street 1:811 AINSWORTH DR STE 103
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301-1687
Practice Address - Country:US
Practice Address - Phone:928-771-5548
Practice Address - Fax:928-771-5549
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-12
Last Update Date:2010-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ22747207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ176950Medicaid
AZZ100903Medicare PIN