MEDICARE: EXCEPTIONAL PHYSICIANS GROUP PRESCOTT HOSPITAL PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207PE0004X	Emergency Medical Services (Emergency Medicine) Physician

General Provider Information

NPI Number	:	1720807670
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EXCEPTIONAL PHYSICIANS GROUP PRESCOTT HOSPITAL PLLC

Provider Business Mailing Address
First Line	:	3514 CEDAR SPRINGS RD
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75219-4901
Country	:	US
Telephone Number	:	972-740-9335
Fax Number	:	469-807-1208

Provider Business Practice Location Address
First Line	:	4822 E STATE ROUTE 69
Second Line	:
City	:	PRESCOTT
State	:	AZ
Zip	:	86301-6885
Country	:	US
Telephone Number	:	972-740-9335
Fax Number	:	469-807-1208

Authorized Official
Title or Position	:	CREDENTIALING SPECIALIST
Name	:	RONALD IVAN COLLINS
Credential	:
Telephone Number	:	972-740-9335

Provider Enumeration Date	:	10/08/2024
Last Update Date	:	02/26/2025

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