Provider Demographics
NPI:1710294756
Name:TRACY CAMPBELL MD LLC
Entity Type:Organization
Organization Name:TRACY CAMPBELL MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:
Authorized Official - Last Name:CAMPBELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:708-450-5086
Mailing Address - Street 1:675 W NORTH AVE STE 506
Mailing Address - Street 2:
Mailing Address - City:MELROSE PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60160-1626
Mailing Address - Country:US
Mailing Address - Phone:708-450-5086
Mailing Address - Fax:708-345-4075
Practice Address - Street 1:675 W NORTH AVE STE 506
Practice Address - Street 2:
Practice Address - City:MELROSE PARK
Practice Address - State:IL
Practice Address - Zip Code:60160-1626
Practice Address - Country:US
Practice Address - Phone:708-450-5086
Practice Address - Fax:708-345-4075
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-13
Last Update Date:2011-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036120737207N00000X, 207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Multi-Specialty