Provider Demographics
NPI:1518953116
Name:TRACY, CHARLES ALAN (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:ALAN
Last Name:TRACY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 MEDICAL PARK
Mailing Address - Street 2:SUITE 200
Mailing Address - City:WHEELING
Mailing Address - State:WV
Mailing Address - Zip Code:26003-6392
Mailing Address - Country:US
Mailing Address - Phone:304-242-0590
Mailing Address - Fax:304-242-9740
Practice Address - Street 1:40 MEDICAL PARK
Practice Address - Street 2:SUITE 200
Practice Address - City:WHEELING
Practice Address - State:WV
Practice Address - Zip Code:26003-6392
Practice Address - Country:US
Practice Address - Phone:304-242-0590
Practice Address - Fax:304-242-9740
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2008-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV148932086S0105X, 2086S0122X
OH350548282086S0105X, 2086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
No2086S0105XAllopathic & Osteopathic PhysiciansSurgerySurgery of the Hand
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0114127000Medicaid
14893OtherHMO
OH0859085Medicaid
OH0859085Medicaid
WV0114127000Medicaid
OH0727994Medicare ID - Type Unspecified