1295046282 NPI number — MS. TRACY ELIZABETH GANNON MSPT

Table of content: MS. TRACY ELIZABETH GANNON MSPT (NPI 1295046282)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295046282 NPI number — MS. TRACY ELIZABETH GANNON MSPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GANNON
Provider First Name:
TRACY
Provider Middle Name:
ELIZABETH
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
MSPT
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:
1295046282
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/24/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
100 HARTSHORN ROAD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PROVIDENCE
Provider Business Mailing Address State Name:
RI
Provider Business Mailing Address Postal Code:
02906
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
401-885-0069
Provider Business Mailing Address Fax Number:
401-885-0071

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5600 POST ROAD
Provider Second Line Business Practice Location Address:
SUITE 116
Provider Business Practice Location Address City Name:
EAST GREENWICH
Provider Business Practice Location Address State Name:
RI
Provider Business Practice Location Address Postal Code:
02818
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
401-885-0069
Provider Business Practice Location Address Fax Number:
401-885-0071
Provider Enumeration Date:
06/24/2010

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: 225100000X , with the licence number:  PT01111 , registered in the state of RI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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