1134245442 NPI number — DR. TRACY B TRELOAR MD

Table of content: DR. TRACY B TRELOAR MD (NPI 1134245442)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134245442 NPI number — DR. TRACY B TRELOAR MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TRELOAR
Provider First Name:
TRACY
Provider Middle Name:
B
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GELSKE
Provider Other First Name:
TRACY
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MAIDEN NAME
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1134245442
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/03/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1 SEAGATE STE 800
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TOLEDO
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
43604-1558
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
517-423-4777
Provider Business Mailing Address Fax Number:
517-423-7257

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6869 S OCCIDENTAL RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TECUMSEH
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49286-9784
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
517-423-4777
Provider Business Practice Location Address Fax Number:
517-423-7257
Provider Enumeration Date:
03/21/2007

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: 208000000X , with the licence number:  35.096222 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X , with the licence number: 4301096739 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 4301096739 . This is a "STATE LICENSE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: LL1699 . This is a "MEDICAL LICENSE" identifier , issued by the state of ( NV ) . This identifiers is of the category "OTHER".
  • Identifier: 1134245442 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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