Provider Demographics
NPI:1295927226
Name:PETRIDES, TRACEY F (MD)
Entity type:Individual
Prefix:DR
First Name:TRACEY
Middle Name:F
Last Name:PETRIDES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:5779 GETWELL ROAD
Mailing Address - Street 2:BUILDING D, SUITE 3
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38672
Mailing Address - Country:US
Mailing Address - Phone:662-510-6507
Mailing Address - Fax:662-510-6508
Practice Address - Street 1:5779 GETWELL ROAD
Practice Address - Street 2:BUILDING D, SUITE 3
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38672
Practice Address - Country:US
Practice Address - Phone:662-510-6507
Practice Address - Fax:662-510-6508
Is Sole Proprietor?:No
Enumeration Date:2007-08-14
Last Update Date:2012-02-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MS17839207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSH11075Medicare UPIN
H11075Medicare UPIN
MS080005201Medicare PIN