Provider Demographics
NPI:1770631343
Name:TRACY, SUSANNE (MD)
Entity Type:Individual
Prefix:MISS
First Name:SUSANNE
Middle Name:
Last Name:TRACY
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 1:2333 BIDDLE AVE
Mailing Address - Street 2:
Mailing Address - City:WYANDOTTE
Mailing Address - State:MI
Mailing Address - Zip Code:48192-4668
Mailing Address - Country:US
Mailing Address - Phone:734-246-6000
Mailing Address - Fax:
Practice Address - Street 1:653 W 8TH ST # FC-12
Practice Address - Street 2:FACULTY CLINIC 3RD FLOOR
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32209-6511
Practice Address - Country:US
Practice Address - Phone:904-244-3903
Practice Address - Fax:904-244-3870
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2008-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLTRN7093208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery