Provider Demographics
NPI:1255387080
Name:LIM, TRACY A (MD)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:A
Last Name:LIM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:805 COLUMBIA RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:WESTLAKE
Mailing Address - State:OH
Mailing Address - Zip Code:44145-1487
Mailing Address - Country:US
Mailing Address - Phone:440-808-1925
Mailing Address - Fax:440-808-1926
Practice Address - Street 1:805 COLUMBIA RD
Practice Address - Street 2:SUITE 102
Practice Address - City:WESTLAKE
Practice Address - State:OH
Practice Address - Zip Code:44145-1487
Practice Address - Country:US
Practice Address - Phone:440-808-1925
Practice Address - Fax:440-808-1926
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2009-01-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OH35070421208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2022466Medicaid
OH0848024Medicare PIN
G73158Medicare UPIN
OH2022466Medicaid