Provider Demographics
NPI:1386650075
Name:MCFALL, TRACY LYNN (MD)
Entity Type:Individual
Prefix:DR
First Name:TRACY
Middle Name:LYNN
Last Name:MCFALL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 BEE ST
Mailing Address - Street 2:ATTN: 117, DEPT OF PM&R
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29401-5703
Mailing Address - Country:US
Mailing Address - Phone:843-789-7315
Mailing Address - Fax:843-789-6211
Practice Address - Street 1:109 BEE ST
Practice Address - Street 2:ATTN: 117, DEPT OF PM&R
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29401-5703
Practice Address - Country:US
Practice Address - Phone:843-789-7315
Practice Address - Fax:843-789-6211
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC15020208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCTL5296Medicaid
SCTL5296Medicaid
SCQ26842081Medicare ID - Type Unspecified