Healthcare Provider Details

I. General information

NPI: 1902858533
Provider Name (Legal Business Name): PRESCOTT CARDIOLOGY, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/16/2006
Last Update Date: 11/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

804 AINSWORTH DR SUITE 102
PRESCOTT AZ
86301-1624
US

IV. Provider business mailing address

804 AINSWORTH DR SUITE 102
PRESCOTT AZ
86301-1624
US

V. Phone/Fax

Practice location:
  • Phone: 928-776-0601
  • Fax: 928-776-0620
Mailing address:
  • Phone: 928-776-0601
  • Fax: 928-776-0620

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number26235
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code207RS0012X
TaxonomySleep Medicine (Internal Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. DOUGLAS WAYNE ROTHROCK
Title or Position: OWNER/PROVIDER
Credential: M.D.
Phone: 928-776-0601