Provider Demographics
NPI:1487854014
Name:TRACY, BRADFORD A (PT)
Entity Type:Individual
Prefix:
First Name:BRADFORD
Middle Name:A
Last Name:TRACY
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2900 FOXFIELD RD
Mailing Address - Street 2:SUITE 205
Mailing Address - City:ST CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60174-5799
Mailing Address - Country:US
Mailing Address - Phone:630-797-4343
Mailing Address - Fax:630-797-4349
Practice Address - Street 1:2900 FOXFIELD RD
Practice Address - Street 2:SUITE 205
Practice Address - City:ST CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60174-5799
Practice Address - Country:US
Practice Address - Phone:630-797-4343
Practice Address - Fax:630-797-4349
Is Sole Proprietor?:No
Enumeration Date:2007-07-22
Last Update Date:2009-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.013634225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK47338Medicare PIN