Provider Demographics
NPI:1972825057
Name:TRACEY J. MORENO, MD, LLC
Entity Type:Organization
Organization Name:TRACEY J. MORENO, MD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:TRACEY
Authorized Official - Middle Name:JUDITH
Authorized Official - Last Name:MORENO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:609-921-1424
Mailing Address - Street 1:601 EWING ST STE C13
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:NJ
Mailing Address - Zip Code:08540-2758
Mailing Address - Country:US
Mailing Address - Phone:609-921-1424
Mailing Address - Fax:609-924-5759
Practice Address - Street 1:601 EWING ST STE C13
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:NJ
Practice Address - Zip Code:08540-2758
Practice Address - Country:US
Practice Address - Phone:609-921-1424
Practice Address - Fax:609-924-5759
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-17
Last Update Date:2011-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA04597200207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJC59251Medicare UPIN