Provider Demographics
NPI:1750336889
Name:TRACY, PATRICK TERENCE (MD)
Entity type:Individual
Prefix:
First Name:PATRICK
Middle Name:TERENCE
Last Name:TRACY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 E PENNSYLVANIA AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61603-3089
Mailing Address - Country:US
Mailing Address - Phone:309-624-4000
Mailing Address - Fax:309-624-4010
Practice Address - Street 1:200 E PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61603-3089
Practice Address - Country:US
Practice Address - Phone:309-624-4000
Practice Address - Fax:309-624-4010
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2016-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036069397207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036069397Medicaid
IL036069397Medicaid