Provider Demographics
NPI:1659319150
Name:TRACY FAMILY PRACTICE CLINIC PA
Entity Type:Organization
Organization Name:TRACY FAMILY PRACTICE CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WALLACE
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:TRACY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:870-946-4505
Mailing Address - Street 1:1940 S WHITEHEAD DR
Mailing Address - Street 2:
Mailing Address - City:DE WITT
Mailing Address - State:AR
Mailing Address - Zip Code:72042-2906
Mailing Address - Country:US
Mailing Address - Phone:870-946-4505
Mailing Address - Fax:870-946-2428
Practice Address - Street 1:1940 S WHITEHEAD DR
Practice Address - Street 2:
Practice Address - City:DE WITT
Practice Address - State:AR
Practice Address - Zip Code:72042-2906
Practice Address - Country:US
Practice Address - Phone:870-946-4505
Practice Address - Fax:870-946-2428
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-04
Last Update Date:2010-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC7340305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR50594Medicare ID - Type Unspecified
ARE02920Medicare UPIN
AR117726002Medicare ID - Type Unspecified