1699757591 NPI number — ELIZABETH TRACY M.D.

Table of content: ELIZABETH TRACY M.D. (NPI 1699757591)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699757591 NPI number — ELIZABETH TRACY M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TRACY
Provider First Name:
ELIZABETH
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1699757591
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/01/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 23340
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT LOUIS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63156-3340
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-645-3743
Provider Business Mailing Address Fax Number:
314-647-7967

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1027 BELLEVUE AVE
Provider Second Line Business Practice Location Address:
SUITE 107
Provider Business Practice Location Address City Name:
SAINT LOUIS
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63117-1851
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-645-3743
Provider Business Practice Location Address Fax Number:
314-647-7967
Provider Enumeration Date:
11/16/2005

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: 207R00000X , with the licence number:  R6J71 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0400404 . This is a "UHC" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 000000010039 . This is a "ESSENCE" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 4090137 . This is a "AETNA" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 127483 . This is a "GHP" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 16533 . This is a "BCBS" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: E62302 . This is a "MERCY" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 101209 . This is a "HEALTHLINK" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".




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