Basic Information
| Provider Information | |||||||||
| NPI: | 1912973314 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PRINCE | ||||||||
| FirstName: | BEVERLY | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1001 EAST SECOND STREET | ||||||||
| Address2: | |||||||||
| City: | COUDERSORT | ||||||||
| State: | PA | ||||||||
| PostalCode: | 169158161 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8142749300 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1001 EAST SECOND STREET | ||||||||
| Address2: | |||||||||
| City: | COUDERSORT | ||||||||
| State: | PA | ||||||||
| PostalCode: | 169158161 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8142749300 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/24/2006 | ||||||||
| LastUpdateDate: | 09/11/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Y00000X | AP3043914 | NY | Y | Allopathic & Osteopathic Physicians | Otolaryngology |
ID Information
| ID | Type | State | Issuer | Description | 040046857 | 01 | RAILROAD | OTHER | P010139747 | 01 | BCBS ROCHESTER ROCH BLUES | OTHER | 1397470B | 01 | WORMANS COMP | OTHER | 000914181003 | 01 | BUFFALO BLUES | OTHER | 08842108 | 01 | N AMERICAN PREFERRED | OTHER | MDG998 | 01 | PREFERRED CARE | OTHER | P010139747 | 01 | BLUE CHOICE | OTHER | 000914181003 | 01 | COMMUNITY BLUE | OTHER | 00869163 | 05 | NY | MEDICAID | 00040440802 | 01 | UNIVERA | OTHER | 0699696 | 01 | GHI | OTHER | 1011404 | 01 | IND HEALTH | OTHER |