Provider Demographics
NPI:1063472207
Name:ROBERTS, TRACY LYNN (MD)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:LYNN
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:TRACY
Other - Middle Name:LYNN
Other - Last Name:CROSSWHITE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 3262
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65808-3262
Mailing Address - Country:US
Mailing Address - Phone:417-885-3888
Mailing Address - Fax:417-881-7268
Practice Address - Street 1:3850 S NATIONAL AVE
Practice Address - Street 2:SUITE 300
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-5287
Practice Address - Country:US
Practice Address - Phone:417-269-6170
Practice Address - Fax:417-269-6992
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2023-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR2P742085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO300100943OtherRRR MEDICARE
MO1256OtherBLUE
MO209728914Medicaid
AR138386001Medicaid
MOP00807645OtherMEDICARE RAILROAD
MO300100943OtherRRR MEDICARE
MOP00807645OtherMEDICARE RAILROAD
AR138386001Medicaid