Provider Demographics
NPI:1275509275
Name:NEUENDORF, TRACY L (DO)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:L
Last Name:NEUENDORF
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 1:1011 BOARDMAN CANFIELD RD
Mailing Address - Street 2:
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44512-4226
Mailing Address - Country:US
Mailing Address - Phone:330-629-2888
Mailing Address - Fax:330-629-8940
Practice Address - Street 1:1011 BOARDMAN CANFIELD RD
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44512-4226
Practice Address - Country:US
Practice Address - Phone:330-629-2888
Practice Address - Fax:330-629-8940
Is Sole Proprietor?:No
Enumeration Date:2006-02-28
Last Update Date:2020-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34.003509207LA0401X
OH34-00-3509-N207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No207LA0401XAllopathic & Osteopathic PhysiciansAnesthesiologyAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000403561OtherHIGHMARK BC/BS
PA0010273680005Medicaid
OH127674OtherANTHEM
OH0601834Medicaid
PA0010273680005Medicaid
OH000403561OtherHIGHMARK BC/BS