Provider Demographics
NPI:1619928223
Name:TRACC, PA
Entity Type:Organization
Organization Name:TRACC, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:C
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:817-332-9957
Mailing Address - Street 1:PO BOX 1559
Mailing Address - Street 2:
Mailing Address - City:GRANBURY
Mailing Address - State:TX
Mailing Address - Zip Code:76048-8559
Mailing Address - Country:US
Mailing Address - Phone:817-332-9957
Mailing Address - Fax:817-336-3130
Practice Address - Street 1:757 8TH AVE STE 1
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2522
Practice Address - Country:US
Practice Address - Phone:817-332-9957
Practice Address - Fax:817-336-3130
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-16
Last Update Date:2020-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX079753201Medicaid
TX00064KMedicare ID - Type Unspecified