Provider Demographics
NPI:1508996166
Name:EDELMANN, TRACY LYNN (DC)
Entity Type:Individual
Prefix:DR
First Name:TRACY
Middle Name:LYNN
Last Name:EDELMANN
Suffix:
Gender:F
Credentials:DC
Other - Prefix:DR
Other - First Name:TRACY
Other - Middle Name:LYNN
Other - Last Name:EDELMANN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DC
Mailing Address - Street 1:8229 CLAYTON RD
Mailing Address - Street 2:STE 204
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63117-1155
Mailing Address - Country:US
Mailing Address - Phone:314-991-5655
Mailing Address - Fax:
Practice Address - Street 1:8229 CLAYTON RD
Practice Address - Street 2:STE 204
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63117-1155
Practice Address - Country:US
Practice Address - Phone:314-991-5655
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-06
Last Update Date:2014-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO006482111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOMA3182OtherMEDICARE PTAN
MO188898OtherANTHEM BLUE CROSS
MOMA3182001OtherMEDICARE PTAN
MO43-1752340OtherFED ID NUMBER
MO000031455Medicare ID - Type UnspecifiedMEDICARE NUMBER
MOMA3182OtherMEDICARE PTAN