1659380566 NPI number — TRACY ELIZABETH HARDWICK MD

Table of content: TRACY ELIZABETH HARDWICK MD (NPI 1659380566)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659380566 NPI number — TRACY ELIZABETH HARDWICK MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HARDWICK
Provider First Name:
TRACY
Provider Middle Name:
ELIZABETH
Provider Name Prefix Text:
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:
PFEIFFER
Provider Other First Name:
TRACY
Provider Other Middle Name:
ELIZABETH
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1659380566
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/11/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 742785
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOS ANGELES
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90074-2785
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-687-4900
Provider Business Mailing Address Fax Number:
541-242-4364

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3915 RIVER RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EUGENE
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97404-1230
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-688-9140
Provider Business Practice Location Address Fax Number:
541-689-0049
Provider Enumeration Date:
08/07/2006

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: 207Q00000X , with the licence number:  MD25670 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 500659426 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".




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