Basic Information
| Provider Information | |||||||||
| NPI: | 1477506251 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TRACY | ||||||||
| FirstName: | JERRY | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | III | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11350 MCCORMICK RD STE 501 | ||||||||
| Address2: | |||||||||
| City: | HUNT VALLEY | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210311002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7039148000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 308 S HARBOR CITY BLVD STE A | ||||||||
| Address2: | |||||||||
| City: | MELBOURNE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329011500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3217330064 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2006 | ||||||||
| LastUpdateDate: | 05/18/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/18/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208VP0000X | ME154017 | FL | Y | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine | 208VP0000X | 35064726 | OH | N | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine |
No ID Information.