1043250608 NPI number — TRACEY R BURNS DPM

Table of content: TRACEY R BURNS DPM (NPI 1043250608)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043250608 NPI number — TRACEY R BURNS DPM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BURNS
Provider First Name:
TRACEY
Provider Middle Name:
R
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DPM
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BURNS-SGAMBATTI
Provider Other First Name:
TRACEY
Provider Other Middle Name:
R
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
DPM
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1043250608
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/14/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4609 BEACH RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MEDINA
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44256-8461
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
330-696-1947
Provider Business Mailing Address Fax Number:
440-816-5306

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
575 WHITE POND DR
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
AKRON
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44320-1184
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
330-835-1629
Provider Business Practice Location Address Fax Number:
330-835-3863
Provider Enumeration Date:
06/08/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 213EP1101X , with the licence number:  36-00-3188 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2383755 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000201218 . This is a "ANTHEM" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 2700867 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 94557 . This is a "QUALCHOICE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".




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