Provider Demographics
NPI:1831150747
Name:PRESCOTT FAMILY CLINIC P A
Entity type:Organization
Organization Name:PRESCOTT FAMILY CLINIC P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:CLARENCE
Authorized Official - Last Name:YOUNG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:870-887-6651
Mailing Address - Street 1:301 HALE AVE
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AR
Mailing Address - Zip Code:71857-3330
Mailing Address - Country:US
Mailing Address - Phone:870-887-6651
Mailing Address - Fax:870-887-2008
Practice Address - Street 1:301 HALE AVE
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AR
Practice Address - Zip Code:71857-3330
Practice Address - Country:US
Practice Address - Phone:870-887-6651
Practice Address - Fax:870-887-2008
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-30
Last Update Date:2013-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR56900OtherBCBS
AR1831150747Medicaid
ARDG5104OtherGBA RAILROAD
AR1831150747Medicaid