Provider Demographics
NPI:1083651533
Name:BEVERLEY, TRACEY D (MD)
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:D
Last Name:BEVERLEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:304 WRIGHT STREET
Mailing Address - Street 2:
Mailing Address - City:SWEETWATER
Mailing Address - State:TN
Mailing Address - Zip Code:37874-2823
Mailing Address - Country:US
Mailing Address - Phone:865-213-8336
Mailing Address - Fax:865-213-8359
Practice Address - Street 1:321 TELLICO STREET
Practice Address - Street 2:
Practice Address - City:MADISONVILLE
Practice Address - State:TN
Practice Address - Zip Code:37354-1194
Practice Address - Country:US
Practice Address - Phone:865-213-8594
Practice Address - Fax:865-213-8359
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-01
Last Update Date:2013-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD37666207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ000340Medicaid
TN4330111OtherBLUE CROSS BLUE SHIELD
TN4330111OtherBLUE CROSS BLUE SHIELD
TNQ000340Medicaid