Provider Demographics
NPI:1952337131
Name:KINIGAKIS, TRACEY DAWN (MD)
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:DAWN
Last Name:KINIGAKIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:TRACEY
Other - Middle Name:DAWN
Other - Last Name:QUART
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:10168 SUSAN CT
Mailing Address - Street 2:
Mailing Address - City:ROSCOE
Mailing Address - State:IL
Mailing Address - Zip Code:61073-9309
Mailing Address - Country:US
Mailing Address - Phone:815-623-1354
Mailing Address - Fax:
Practice Address - Street 1:1495 NORTHROCK CT
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61103-1233
Practice Address - Country:US
Practice Address - Phone:815-618-8116
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-23
Last Update Date:2009-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036095213207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL834340OtherMEDICARE GROUP NUMBER
IL834370OtherMEDICARE GROUP NUMBER
IL834330OtherMEDICARE GROUP NUMBER
IL553180OtherMEDICARE GROUP NUMBER
IL846930OtherMEDICARE GROUP NUMBER
IL834340OtherMEDICARE GROUP NUMBER
IL846930OtherMEDICARE GROUP NUMBER
IL553180029Medicare PIN
IL834330OtherMEDICARE GROUP NUMBER
IL834370002Medicare PIN