Provider Demographics
NPI:1700809373
Name:GROTRIAN, TRACY L (DO)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:L
Last Name:GROTRIAN
Suffix:
Gender:F
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:P.O. BOX 6002
Mailing Address - Street 2:
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61803-6002
Mailing Address - Country:US
Mailing Address - Phone:217-326-8300
Mailing Address - Fax:
Practice Address - Street 1:1701 W CURTIS ROAD
Practice Address - Street 2:FAMILY MEDICINE/CONVENIENT CARE
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61822
Practice Address - Country:US
Practice Address - Phone:217-365-6201
Practice Address - Fax:217-326-1234
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2013-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036110788207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00192495OtherRAILROAD
IL0533210001OtherDMERC
I17988Medicare UPIN
ILK10847Medicare PIN
ILI17988Medicare UPIN
IL0533210001OtherDMERC
ILIL3270416Medicare PIN