1710950464 NPI number — DR. TRACI A KURTZER MD

Table of content: DR. TRACI A KURTZER MD (NPI 1710950464)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710950464 NPI number — DR. TRACI A KURTZER MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KURTZER
Provider First Name:
TRACI
Provider Middle Name:
A
Provider Name Prefix Text:
DR.
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:
ARMER
Provider Other First Name:
TRACI
Provider Other Middle Name:
L
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1710950464
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
636 CHURCH ST
Provider Second Line Business Mailing Address:
STE 217
Provider Business Mailing Address City Name:
EVANSTON
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60201
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-328-0238
Provider Business Mailing Address Fax Number:
847-328-1425

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
636 CHURCH ST
Provider Second Line Business Practice Location Address:
STE 217
Provider Business Practice Location Address City Name:
EVANSTON
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60201
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-328-0238
Provider Business Practice Location Address Fax Number:
847-328-1425
Provider Enumeration Date:
02/10/2006

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: 207V00000X , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 01632915 . This is a "BCBS" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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