1689922585 NPI number — MRS. TRACY LEE EAGLE MS

Table of content: MRS. TRACY LEE EAGLE MS (NPI 1689922585)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689922585 NPI number — MRS. TRACY LEE EAGLE MS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EAGLE
Provider First Name:
TRACY
Provider Middle Name:
LEE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MS
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GALLATIN
Provider Other First Name:
TRACY
Provider Other Middle Name:
LEE
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
BS, FAODP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1689922585
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/30/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
96 E GORDONVILLE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MIDLAND
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48640-8384
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
989-790-3366
Provider Business Mailing Address Fax Number:
989-790-5027

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4151 SHRESTHA DRIVE
Provider Second Line Business Practice Location Address:
STE D
Provider Business Practice Location Address City Name:
SAGINAW
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48603-2190
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
989-220-3060
Provider Business Practice Location Address Fax Number:
989-790-5027
Provider Enumeration Date:
08/27/2012

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: 101YA0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YP2500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: ON80300 . This is a "MEDICARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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