Provider Demographics
NPI:1700853660
Name:BLACK, TRACY M (MD)
Entity Type:Individual
Prefix:DR
First Name:TRACY
Middle Name:M
Last Name:BLACK
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 1:5213 S ALSTON AVE
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27713-4430
Mailing Address - Country:US
Mailing Address - Phone:919-620-4467
Mailing Address - Fax:
Practice Address - Street 1:4220 N ROXBORO ST
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27704-1826
Practice Address - Country:US
Practice Address - Phone:919-471-1518
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-01
Last Update Date:2013-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9400724207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8912086Medicaid
NCP00163549OtherRAILROAD
NC2337913OtherMEDICARE LEGACY ID
NC4646370OtherAETNA
NC12086OtherBCBS
NC2205674DMedicare PIN
NC12086OtherBCBS
NCF94543Medicare UPIN
NC2337913OtherMEDICARE LEGACY ID
NC8912086Medicaid