Basic Information
| Provider Information | |||||||||
| NPI: | 1003848763 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TRACY | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | N | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 635283 | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452635283 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8597814111 | ||||||||
| FaxNumber: | 8594415214 | ||||||||
| Practice Location | |||||||||
| Address1: | 413 SOUTH LOOP ROAD | ||||||||
| Address2: | |||||||||
| City: | EDGEWOOD | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410175446 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593013800 | ||||||||
| FaxNumber: | 8593013987 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2006 | ||||||||
| LastUpdateDate: | 08/30/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/30/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 26618 | KY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0101286 | 05 | OH | MEDICAID | 080092534 | 01 | KY | RAILROAD MEDICARE | OTHER | P00839856 | 01 | KY | RAILROAD MEDICARE | OTHER | 64266182 | 05 | KY | MEDICAID |