Provider Demographics
NPI:1558329433
Name:TRACEY, AUDREY (MD)
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:
Last Name:TRACEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:87 NORTH MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:LEOMINSTER
Mailing Address - State:MA
Mailing Address - Zip Code:01453
Mailing Address - Country:US
Mailing Address - Phone:978-534-8701
Mailing Address - Fax:978-534-8705
Practice Address - Street 1:87 NORTH MAIN STREET
Practice Address - Street 2:
Practice Address - City:LEOMINSTER
Practice Address - State:MA
Practice Address - Zip Code:01453
Practice Address - Country:US
Practice Address - Phone:798-534-8701
Practice Address - Fax:978-534-8705
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-02
Last Update Date:2020-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA152307207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA$$$$$$$$$OtherSOCIAL SECURITY
MAG44129Medicare UPIN