Provider Demographics
NPI:1972696367
Name:MILLER, TRACEY L (MD)
Entity Type:Individual
Prefix:DR
First Name:TRACEY
Middle Name:L
Last Name:MILLER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2401 GILLHAM RD
Mailing Address - Street 2:PROVIDER ENROLLMENT DEPARTMENT
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64108-4619
Mailing Address - Country:US
Mailing Address - Phone:816-234-3000
Mailing Address - Fax:816-302-9939
Practice Address - Street 1:5808 W 110TH ST
Practice Address - Street 2:
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66211-2504
Practice Address - Country:US
Practice Address - Phone:913-696-8000
Practice Address - Fax:816-302-9939
Is Sole Proprietor?:No
Enumeration Date:2006-09-30
Last Update Date:2019-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0424509208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100143930AMedicaid
19401018OtherBCBS KANSAS CITY
KS619010OtherBCBS KANSAS
MO205547706Medicaid