Provider Demographics
NPI:1053335307
Name:PRINCE, TRACY (DO)
Entity Type:Individual
Prefix:DR
First Name:TRACY
Middle Name:
Last Name:PRINCE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2030 THISTLE HILL DR
Mailing Address - Street 2:
Mailing Address - City:SPRING GROVE
Mailing Address - State:PA
Mailing Address - Zip Code:17362-1159
Mailing Address - Country:US
Mailing Address - Phone:717-225-9869
Mailing Address - Fax:717-225-6552
Practice Address - Street 1:2030 THISTLE HILL DR
Practice Address - Street 2:SUITE 100
Practice Address - City:SPRING GROVE
Practice Address - State:PA
Practice Address - Zip Code:17362-1159
Practice Address - Country:US
Practice Address - Phone:717-225-9869
Practice Address - Fax:717-225-6552
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2021-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS010945L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA2525814OtherCIGNA
PA7989331OtherAETNA
PA50097247OtherCAPITAL BC
PA1386391OtherHIGHMARK BS
PA0019165970004Medicaid
PAP010738OtherGATEWAY HEALTH PLAN
PA2525814OtherCIGNA
PA803132ZEA5Medicare PIN
PA7989331OtherAETNA