1275509275 NPI number — TRACY L NEUENDORF D.O.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275509275 NPI number — TRACY L NEUENDORF D.O.

Organization/Personal Information

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

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:
1275509275
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/30/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1011 BOARDMAN CANFIELD RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
YOUNGSTOWN
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44512-4226
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
330-629-2888
Provider Business Mailing Address Fax Number:
330-629-8940

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1011 BOARDMAN CANFIELD RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
YOUNGSTOWN
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44512-4226
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
330-629-2888
Provider Business Practice Location Address Fax Number:
330-629-8940
Provider Enumeration Date:
02/28/2006

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: 207LA0401X , with the licence number:  34.003509 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207LP2900X , with the licence number: 34-00-3509-N , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000403561 . This is a "HIGHMARK BC/BS" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 0010273680005 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 127674 . This is a "ANTHEM" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 0601834 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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