1740282136 NPI number — SHERRILL TRACY MD

Table of content: SHERRILL TRACY MD (NPI 1740282136)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740282136 NPI number — SHERRILL TRACY MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TRACY
Provider First Name:
SHERRILL
Provider Middle Name:
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:
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:
1740282136
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
133 PLEASANT STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BERLIN
Provider Business Mailing Address State Name:
NH
Provider Business Mailing Address Postal Code:
03570
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
603-752-2040
Provider Business Mailing Address Fax Number:
603-752-7797

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2 BROADWAY STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GORHAM
Provider Business Practice Location Address State Name:
NH
Provider Business Practice Location Address Postal Code:
03581
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
603-466-2741
Provider Business Practice Location Address Fax Number:
603-466-2953
Provider Enumeration Date:
08/15/2005

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: 207Q00000X , with the licence number:  6910 , registered in the state of NH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 6910 . This is a "STATE LICENSE #" identifier , issued by the state of ( NH ) . This identifiers is of the category "OTHER".
  • Identifier: 81083242 , issued by the state of ( NH ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00120775 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 5635115001 . This is a "CIGNA HEALTHCARE" identifier , issued by the state of ( NH ) . This identifiers is of the category "OTHER".
  • Identifier: 0104864YPNH02 . This is a "ANTHEM BC/BS" identifier , issued by the state of ( NH ) . This identifiers is of the category "OTHER".




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