Provider Demographics
NPI:1043282684
Name:SHAUB, TRACY LYNNE (DO)
Entity Type:Individual
Prefix:DR
First Name:TRACY
Middle Name:LYNNE
Last Name:SHAUB
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:246 PARKS HALL
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:OH
Mailing Address - Zip Code:45701-1359
Mailing Address - Country:US
Mailing Address - Phone:740-593-2672
Mailing Address - Fax:740-593-2905
Practice Address - Street 1:2ND FLOOR PARKS HALL
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:OH
Practice Address - Zip Code:45701
Practice Address - Country:US
Practice Address - Phone:740-593-2516
Practice Address - Fax:740-593-2905
Is Sole Proprietor?:No
Enumeration Date:2006-02-07
Last Update Date:2017-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34005750M207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0165922Medicaid
OH0165922Medicaid
OHF74897Medicare UPIN