Provider Demographics
NPI:1023059037
Name:TRAICOFF, RICHARD W (DO)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:W
Last Name:TRAICOFF
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 634087
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263
Mailing Address - Country:US
Mailing Address - Phone:800-540-8739
Mailing Address - Fax:616-975-9827
Practice Address - Street 1:28050 GRAND RIVER AVENUE
Practice Address - Street 2:ER DEPARTMENT
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48336
Practice Address - Country:US
Practice Address - Phone:248-471-8000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-09
Last Update Date:2011-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIRT011776207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI114570790Medicaid
MIN83060003Medicare ID - Type Unspecified
F78558Medicare UPIN