Provider Demographics
NPI:1013287929
Name:MADISON, TRACY ANNETTE
Entity Type:Individual
Prefix:MRS
First Name:TRACY
Middle Name:ANNETTE
Last Name:MADISON
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 1:485 MCLIN CIR
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:MS
Mailing Address - Zip Code:39073-7939
Mailing Address - Country:US
Mailing Address - Phone:601-845-5827
Mailing Address - Fax:
Practice Address - Street 1:485 MCLIN CIR
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:MS
Practice Address - Zip Code:39073-7939
Practice Address - Country:US
Practice Address - Phone:601-845-5827
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-09
Last Update Date:2012-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS00770423171M00000X
MS00770594171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00770423Medicaid
MS00770594Medicaid