Provider Demographics
NPI:1750542486
Name:MADSEN, TRACY E (MD)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:E
Last Name:MADSEN
Suffix:
Gender:F
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:PO BOX 9484
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02940-9484
Mailing Address - Country:US
Mailing Address - Phone:401-854-2500
Mailing Address - Fax:401-854-2519
Practice Address - Street 1:593 EDDY ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02903-4923
Practice Address - Country:US
Practice Address - Phone:401-519-1604
Practice Address - Fax:401-272-0538
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-25
Last Update Date:2024-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RILP01357207P00000X
RIMD13932207P00000X
VT042.0018047207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI07/22/2012OtherBCBS
RI07/12/12OtherNHPRI
RITM89202Medicaid
RI08/21/2012OtherTUFTS HEALTH PLAN
MA110093030AMedicaid
RI08/10/2012OtherHEALTHNET FED SERVICES
RITM89202Medicaid