Provider Demographics
NPI:1912973314
Name:PRINCE, BEVERLY C (MD)
Entity Type:Individual
Prefix:
First Name:BEVERLY
Middle Name:C
Last Name:PRINCE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 EAST SECOND STREET
Mailing Address - Street 2:
Mailing Address - City:COUDERSORT
Mailing Address - State:PA
Mailing Address - Zip Code:16915-8161
Mailing Address - Country:US
Mailing Address - Phone:814-274-9300
Mailing Address - Fax:
Practice Address - Street 1:1001 EAST SECOND STREET
Practice Address - Street 2:
Practice Address - City:COUDERSORT
Practice Address - State:PA
Practice Address - Zip Code:16915-8161
Practice Address - Country:US
Practice Address - Phone:814-274-9300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-24
Last Update Date:2012-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYAP3043914207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
040046857OtherRAILROAD
P010139747OtherBCBS ROCHESTER ROCH BLUES
1397470BOtherWORMANS COMP
000914181003OtherBUFFALO BLUES
08842108OtherN AMERICAN PREFERRED
MDG998OtherPREFERRED CARE
P010139747OtherBLUE CHOICE
000914181003OtherCOMMUNITY BLUE
NY00869163Medicaid
00040440802OtherUNIVERA
0699696OtherGHI
1011404OtherIND HEALTH
D47377Medicare UPIN
P010139747OtherBLUE CHOICE