Provider Demographics
NPI:1326029158
Name:GIFFORD, TRICIA KAYE (MD)
Entity Type:Individual
Prefix:DR
First Name:TRICIA
Middle Name:KAYE
Last Name:GIFFORD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:TRICIA
Other - Middle Name:KAYE
Other - Last Name:WARNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 775383
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-5383
Mailing Address - Country:US
Mailing Address - Phone:812-376-5315
Mailing Address - Fax:
Practice Address - Street 1:4001 W GOELLER BLVD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:IN
Practice Address - Zip Code:47201-8308
Practice Address - Country:US
Practice Address - Phone:812-375-3330
Practice Address - Fax:812-375-3329
Is Sole Proprietor?:No
Enumeration Date:2005-11-09
Last Update Date:2023-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36101716207Q00000X
IN01063240207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
L76814OtherPIN
IN201311170Medicaid
IL0004132020OtherBCBS
IN000000991452OtherANTHEM PIN
IL036101716Medicaid
IL036101716Medicaid
IN000000991452OtherANTHEM PIN