Provider Demographics
NPI:1093590549
Name:BRACY, TAYLOR
Entity Type:Individual
Prefix:
First Name:TAYLOR
Middle Name:
Last Name:BRACY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1117 LAUREL RD
Mailing Address - Street 2:
Mailing Address - City:EDGEWATER PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:08010-2608
Mailing Address - Country:US
Mailing Address - Phone:609-845-4224
Mailing Address - Fax:
Practice Address - Street 1:12331 ACADEMY RD
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19154-1927
Practice Address - Country:US
Practice Address - Phone:215-576-4796
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-31
Last Update Date:2023-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT0314432081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine