Provider Demographics
NPI:1518901602
Name:THOMAS, TRACEY S (DO)
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:S
Last Name:THOMAS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 746724
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-6724
Mailing Address - Country:US
Mailing Address - Phone:312-733-9730
Mailing Address - Fax:773-866-8014
Practice Address - Street 1:3250 FREEDOM DR
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28208-2817
Practice Address - Country:US
Practice Address - Phone:704-709-6009
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2022-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY02969207Q00000X
OH34.009991207Q00000X
WV2438207Q00000X
NC2012-02056207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV00799629OtherRR MEDICARE
KY64124860Medicaid
KY000000484080OtherANTHEM BCBS
WV3810016933Medicaid
OH2754318Medicaid
WV00799629OtherRR MEDICARE
KY0641227Medicare PIN
KY000000484080OtherANTHEM BCBS
WV4282091Medicare PIN