Provider Demographics
NPI:1326060666
Name:TRACY, TY N (DC)
Entity Type:Individual
Prefix:
First Name:TY
Middle Name:N
Last Name:TRACY
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:444 N STONE ST
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:OH
Mailing Address - Zip Code:43420-1530
Mailing Address - Country:US
Mailing Address - Phone:419-334-7737
Mailing Address - Fax:419-334-2528
Practice Address - Street 1:444 N STONE ST
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:OH
Practice Address - Zip Code:43420-1530
Practice Address - Country:US
Practice Address - Phone:419-334-7737
Practice Address - Fax:419-334-2528
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-24
Last Update Date:2022-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2805111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000362534OtherANTHEM BCBS
7139412OtherAETNA
OH2117220Medicaid
7139412OtherAETNA
OH0875892Medicare PIN