Provider Demographics
NPI:1881622835
Name:PRESCOTT CLINIC P.C.
Entity type:Organization
Organization Name:PRESCOTT CLINIC P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:E
Authorized Official - Last Name:BERNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:989-892-7722
Mailing Address - Street 1:125 N WASHINGTON ST
Mailing Address - Street 2:PO BOX 114
Mailing Address - City:PRESCOTT
Mailing Address - State:MI
Mailing Address - Zip Code:48756-5117
Mailing Address - Country:US
Mailing Address - Phone:989-892-7722
Mailing Address - Fax:989-892-7455
Practice Address - Street 1:125 WASHINGTON
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:MI
Practice Address - Zip Code:48756
Practice Address - Country:US
Practice Address - Phone:989-873-3352
Practice Address - Fax:989-873-3949
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-29
Last Update Date:2018-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X
MI261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Single Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
233873OtherRIVERBEND
MI010F510190OtherBCBS
MI114303974Medicaid
233873OtherRIVERBEND
MI=========101OtherCOMMUNITY CHOICE
MI114303974Medicaid
MIMI1172Medicare PIN