Provider Demographics
NPI:1841206919
Name:KOHL, TRACI M (MD)
Entity Type:Individual
Prefix:
First Name:TRACI
Middle Name:M
Last Name:KOHL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:4131 OREGON PIKE
Mailing Address - Street 2:SUITE C
Mailing Address - City:EPHRATA
Mailing Address - State:PA
Mailing Address - Zip Code:17522-9550
Mailing Address - Country:US
Mailing Address - Phone:717-859-5161
Mailing Address - Fax:717-859-5169
Practice Address - Street 1:446 N READING RD
Practice Address - Street 2:SUITE 301
Practice Address - City:EPHRATA
Practice Address - State:PA
Practice Address - Zip Code:17522-9802
Practice Address - Country:US
Practice Address - Phone:717-733-6546
Practice Address - Fax:717-733-6010
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2015-05-27
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
PAMD417992207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA50051217OtherCAPITAL BLUE
PAP004736OtherGATEWAY
PA1397460OtherBLUE SHIELD
PAP00261141 -GRPDD6938OtherRAILROAD MEDICARE
PAP004736OtherGATEWAY ASSURED
PA01890211Medicaid
PA1397460OtherFREEDOM BLUE
PAP00261141 -GRPDD6938OtherRAILROAD MEDICARE
PA1397460OtherBLUE SHIELD