Provider Demographics
NPI:1548596687
Name:TRACEY, KEVIN THOMAS (MD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:THOMAS
Last Name:TRACEY
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 1:7805 SABALRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:NORTH CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29418-2230
Mailing Address - Country:US
Mailing Address - Phone:843-760-6423
Mailing Address - Fax:
Practice Address - Street 1:7805 SABALRIDGE DR
Practice Address - Street 2:
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29418-2230
Practice Address - Country:US
Practice Address - Phone:843-760-6423
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-25
Last Update Date:2009-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA39276146D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes146D00000XEmergency Medical Service ProvidersPersonal Emergency Response Attendant