Provider Demographics
NPI:1578697074
Name:FITE, TRACY M (MD)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:M
Last Name:FITE
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 1:1 SOUTHTOWNE DR
Mailing Address - Street 2:
Mailing Address - City:POTOSI
Mailing Address - State:MO
Mailing Address - Zip Code:63664-5729
Mailing Address - Country:US
Mailing Address - Phone:573-438-9355
Mailing Address - Fax:
Practice Address - Street 1:1 SOUTHTOWNE DR
Practice Address - Street 2:
Practice Address - City:POTOSI
Practice Address - State:MO
Practice Address - Zip Code:63664-5729
Practice Address - Country:US
Practice Address - Phone:573-438-9355
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-15
Last Update Date:2015-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE5248207Q00000X
MO2009022062207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR165595001Medicaid
ARP00464657OtherRAILROAD MEDICARE
MO431560263OtherTRICARE
MOP01027294OtherRR MCR
AR165595001Medicaid
AR5N957Medicare PIN