Provider Demographics
NPI:1144395682
Name:KYLES, TRACYE DENISE (MD)
Entity Type:Individual
Prefix:DR
First Name:TRACYE
Middle Name:DENISE
Last Name:KYLES
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:P.O. BOX 405827
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-5827
Mailing Address - Country:US
Mailing Address - Phone:870-934-5821
Mailing Address - Fax:870-934-5384
Practice Address - Street 1:5220 PARK AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38119
Practice Address - Country:US
Practice Address - Phone:901-685-8245
Practice Address - Fax:901-685-8248
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2011-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA026279207R00000X, 208000000X
TN44506207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1055531Medicaid
LA4K454C822Medicare PIN
I71385Medicare UPIN
LAI71385Medicare UPIN
LA1055531Medicaid