1639169733 NPI number — DR. TRACY S BYRNE M.D.

Table of content: DR. TRACY S BYRNE M.D. (NPI 1639169733)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639169733 NPI number — DR. TRACY S BYRNE M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BYRNE
Provider First Name:
TRACY
Provider Middle Name:
S
Provider Name Prefix Text:
DR.
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:
1639169733
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/06/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6301 UNIVERSITY COMMONS
Provider Second Line Business Mailing Address:
STE 230
Provider Business Mailing Address City Name:
SOUTH BEND
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46635-1571
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
574-251-2100
Provider Business Mailing Address Fax Number:
574-251-2151

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6301 UNIVERSITY COMMONS
Provider Second Line Business Practice Location Address:
SUITE 310
Provider Business Practice Location Address City Name:
SOUTH BEND
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46635-1571
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
574-232-1471
Provider Business Practice Location Address Fax Number:
574-239-8511
Provider Enumeration Date:
10/28/2005

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: 207V00000X , with the licence number:  10357 , 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: 30011688 , issued by the state of ( NH ) . This identifiers is of the category "MEDICAID".
  • Identifier: HL0041 . This is a "HARVARD PILGRIM" identifier , issued by the state of ( NH ) . This identifiers is of the category "OTHER".
  • Identifier: 364352 . This is a "MVP" identifier , issued by the state of ( NH ) . This identifiers is of the category "OTHER".
  • Identifier: 0704678 . This is a "UNITED HEALTH CARE" identifier , issued by the state of ( NH ) . This identifiers is of the category "OTHER".
  • Identifier: 5084658 . This is a "AETNA" identifier , issued by the state of ( NH ) . This identifiers is of the category "OTHER".
  • Identifier: NH0008644 . This is a "CHAMPUS" identifier , issued by the state of ( NH ) . This identifiers is of the category "OTHER".
  • Identifier: 0105013Y0NH02 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( NH ) . This identifiers is of the category "OTHER".
  • Identifier: 2690350 . This is a "CIGNA" identifier , issued by the state of ( NH ) . This identifiers is of the category "OTHER".




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