Provider Demographics
NPI:1689650848
Name:LILLIE, TRACY A (MD)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:A
Last Name:LILLIE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:4133 MEDICAL CENTER DR
Mailing Address - Street 2:
Mailing Address - City:BROAD TOP
Mailing Address - State:PA
Mailing Address - Zip Code:16621-9001
Mailing Address - Country:US
Mailing Address - Phone:814-635-2916
Mailing Address - Fax:814-635-2918
Practice Address - Street 1:790 BRYAN ST
Practice Address - Street 2:
Practice Address - City:HUNTINGDON
Practice Address - State:PA
Practice Address - Zip Code:16652-2410
Practice Address - Country:US
Practice Address - Phone:814-643-8299
Practice Address - Fax:814-643-8300
Is Sole Proprietor?:No
Enumeration Date:2005-12-20
Last Update Date:2022-08-31
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAMD066530L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0017391890006Medicaid
PAG88813Medicare UPIN
PA0017391890006Medicaid