Basic Information
| Provider Information | |||||||||
| NPI: | 1326136219 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PRESCOTT LUNG PHYSICIANS LTD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 808 AINSWORTH DR | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | PRESCOTT | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 863011625 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4809851093 | ||||||||
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| Practice Location | |||||||||
| Address1: | 808 AINSWORTH DR | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | PRESCOTT | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 863011625 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4809851093 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2006 | ||||||||
| LastUpdateDate: | 06/25/2012 | ||||||||
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| AuthorizedOfficialLastName: | RAUSCHER | ||||||||
| AuthorizedOfficialFirstName: | CLIFFORD | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4809851093 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RP1001X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 290012799 | 01 | AZ | RAIL ROAD MEDICARE | OTHER | AZ0005360 | 01 | AZ | BCBS | OTHER |