Provider Demographics
NPI:1043250608
Name:BURNS, TRACEY R (DPM)
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:R
Last Name:BURNS
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:TRACEY
Other - Middle Name:R
Other - Last Name:BURNS-SGAMBATTI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DPM
Mailing Address - Street 1:4609 BEACH RD
Mailing Address - Street 2:
Mailing Address - City:MEDINA
Mailing Address - State:OH
Mailing Address - Zip Code:44256-8461
Mailing Address - Country:US
Mailing Address - Phone:330-696-1947
Mailing Address - Fax:440-816-5306
Practice Address - Street 1:575 WHITE POND DR
Practice Address - Street 2:SUITE A
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44320-1184
Practice Address - Country:US
Practice Address - Phone:330-835-1629
Practice Address - Fax:330-835-3863
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2012-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36-00-3188213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2383755Medicaid
OH000000201218OtherANTHEM
OH2700867OtherUNITED HEALTHCARE
OH94557OtherQUALCHOICE
OH2383755Medicaid
OHU83275Medicare UPIN