Provider Demographics
NPI:1316031818
Name:TRACY T. PHILLIPS, MD, MEDICAL CORPORATION
Entity Type:Organization
Organization Name:TRACY T. PHILLIPS, MD, MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:T
Authorized Official - Last Name:PHILLIPS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:510-435-3311
Mailing Address - Street 1:2089 VALE ROAD
Mailing Address - Street 2:SUITE 10
Mailing Address - City:SAN PABLO
Mailing Address - State:CA
Mailing Address - Zip Code:94806
Mailing Address - Country:US
Mailing Address - Phone:510-234-4235
Mailing Address - Fax:
Practice Address - Street 1:2089 VALE ROAD
Practice Address - Street 2:SUITE 10
Practice Address - City:SAN PABLO
Practice Address - State:CA
Practice Address - Zip Code:94806
Practice Address - Country:US
Practice Address - Phone:510-234-4235
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2010-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA84062207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty