Provider Demographics
NPI:1881658805
Name:OVERBECK, TRACIE L (MD, PHD)
Entity type:Individual
Prefix:DR
First Name:TRACIE
Middle Name:L
Last Name:OVERBECK
Suffix:
Gender:F
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:DEPT. 453 PO BOX 1000
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38148-0001
Mailing Address - Country:US
Mailing Address - Phone:828-575-2625
Mailing Address - Fax:828-350-2174
Practice Address - Street 1:166 PASADENA DRIVE SUITE 150
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40503-2938
Practice Address - Country:US
Practice Address - Phone:859-276-1452
Practice Address - Fax:859-277-1237
Is Sole Proprietor?:No
Enumeration Date:2006-04-14
Last Update Date:2023-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY40012207K00000X, 207K00000X
TN35886207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYK092670OtherMEDICARE PTAN
KY64086788Medicaid
I05950Medicare UPIN
I05950Medicare UPIN
KY7100172090OtherMEDICAID GROUP
3893526Medicare ID - Type Unspecified