Provider Demographics
NPI:1851479828
Name:TRACY, EILEEN C
Entity Type:Individual
Prefix:
First Name:EILEEN
Middle Name:C
Last Name:TRACY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6310 FAR HILLS AVE
Mailing Address - Street 2:
Mailing Address - City:CENTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45459-2724
Mailing Address - Country:US
Mailing Address - Phone:937-291-0010
Mailing Address - Fax:937-291-9276
Practice Address - Street 1:6310 FAR HILLS AVE
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:45459-2724
Practice Address - Country:US
Practice Address - Phone:937-291-0010
Practice Address - Fax:937-291-9276
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2007-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0626531Medicaid
000000016562OtherANTHEM BCBS
OH0210180002Medicare PIN