Provider Demographics
NPI:1376846469
Name:TRACE MEDICAL CLINIC, PLLC
Entity Type:Organization
Organization Name:TRACE MEDICAL CLINIC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:G
Authorized Official - Last Name:BROWNING
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:662-289-9155
Mailing Address - Street 1:530 VETERANS MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:KOSCIUSKO
Mailing Address - State:MS
Mailing Address - Zip Code:39090-3858
Mailing Address - Country:US
Mailing Address - Phone:662-289-9155
Mailing Address - Fax:662-289-7752
Practice Address - Street 1:530 VETERANS MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:KOSCIUSKO
Practice Address - State:MS
Practice Address - Zip Code:39090-3858
Practice Address - Country:US
Practice Address - Phone:662-289-9155
Practice Address - Fax:662-289-7752
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-10
Last Update Date:2010-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty