1679731822 NPI number — TRACEY NICOLE MCCARTHY DO

Table of content: TRACEY NICOLE MCCARTHY DO (NPI 1679731822)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679731822 NPI number — TRACEY NICOLE MCCARTHY DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCCARTHY
Provider First Name:
TRACEY
Provider Middle Name:
NICOLE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LAYNE
Provider Other First Name:
TRACEY
Provider Other Middle Name:
NICOLE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
DO
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1679731822
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/28/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 60447
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHARLOTTE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28260-0447
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-384-7840
Provider Business Mailing Address Fax Number:
704-384-7830

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
584 HOSPITAL DR
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
BOLIVIA
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28422
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-721-4050
Provider Business Practice Location Address Fax Number:
910-721-4051
Provider Enumeration Date:
05/23/2008

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: 207V00000X , with the licence number:  2008-02036 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 5911526 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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