Provider Demographics
NPI:1780669739
Name:WIMBUSH, TRACY ELIZABETH (MD)
Entity Type:Individual
Prefix:DR
First Name:TRACY
Middle Name:ELIZABETH
Last Name:WIMBUSH
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 1:900 CIRCLE 75 PKWY SE
Mailing Address - Street 2:SUITE 1700
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30339-3035
Mailing Address - Country:US
Mailing Address - Phone:770-953-6929
Mailing Address - Fax:770-953-6972
Practice Address - Street 1:1240 EAGLES LANDING PKWY
Practice Address - Street 2:SUITE 300
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281
Practice Address - Country:US
Practice Address - Phone:770-506-4350
Practice Address - Fax:770-506-9860
Is Sole Proprietor?:No
Enumeration Date:2005-12-13
Last Update Date:2014-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA213411207P00000X
NY243910207P00000X
PAMD433123207P00000X, 207LP2900X
GA068869208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003134595JMedicaid
MA2034247Medicaid
MA468709OtherTUFTS HEALTH PLAN
MAJ27108OtherBCBS MA
GA003134595KMedicaid
GA003134595LMedicaid
MA468709OtherTUFTS HEALTH PLAN
MAA36461Medicare ID - Type Unspecified
GA003134595KMedicaid