1790840296 NPI number — MRS. TRACY WILSON

Table of content: MRS. TRACY WILSON (NPI 1790840296)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790840296 NPI number — MRS. TRACY WILSON

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILSON
Provider First Name:
TRACY
Provider Middle Name:
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
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:
1790840296
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:
2422 SAINT GEORGE WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BROOKEVILLE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
20833-3265
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
301-570-8415
Provider Business Mailing Address Fax Number:
301-570-8415

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2422 SAINT GEORGE WAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BROOKEVILLE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
20833-3265
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-570-8415
Provider Business Practice Location Address Fax Number:
301-570-8415
Provider Enumeration Date:
12/26/2006

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: 225X00000X , with the licence number:  03971 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: J917-0001 . This is a "BCBS PROVIDER NUMBER" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".




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