Provider Demographics
NPI:1811923873
Name:THOMPSON, TRACY EADIE (MD)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:EADIE
Last Name:THOMPSON
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 1:7210 N MAIN ST
Mailing Address - Street 2:STE 205
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48346
Mailing Address - Country:US
Mailing Address - Phone:248-625-9755
Mailing Address - Fax:248-620-9334
Practice Address - Street 1:7210 N MAIN ST
Practice Address - Street 2:STE 205
Practice Address - City:CLARKSTON
Practice Address - State:MI
Practice Address - Zip Code:48346
Practice Address - Country:US
Practice Address - Phone:248-625-9755
Practice Address - Fax:248-620-9334
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MITT407382208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
E16039Medicare UPIN
MIM9503003Medicare ID - Type Unspecified