Provider Demographics
NPI:1841929908
Name:PRESCOTT MEDICAL AND DERMATOLOGY GROUP
Entity type:Organization
Organization Name:PRESCOTT MEDICAL AND DERMATOLOGY GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BURT
Authorized Official - Middle Name:I
Authorized Official - Last Name:FAIBISOFF
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:602-476-4074
Mailing Address - Street 1:804 AINSWORTH DR STE 105
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86301-1624
Mailing Address - Country:US
Mailing Address - Phone:602-476-4074
Mailing Address - Fax:
Practice Address - Street 1:804 AINSWORTH DR STE 105
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301-1624
Practice Address - Country:US
Practice Address - Phone:602-476-4074
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-06-06
Last Update Date:2025-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Multi-Specialty