Provider Demographics
NPI:1124094362
Name:RIORDAN, TRACY M (MD)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:M
Last Name:RIORDAN
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 1:1254 MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:IMPERIAL
Mailing Address - State:MO
Mailing Address - Zip Code:63052
Mailing Address - Country:US
Mailing Address - Phone:636-741-3130
Mailing Address - Fax:
Practice Address - Street 1:1254 MAIN ST
Practice Address - Street 2:
Practice Address - City:IMPERIAL
Practice Address - State:MO
Practice Address - Zip Code:63052-3861
Practice Address - Country:US
Practice Address - Phone:636-741-3130
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-27
Last Update Date:2017-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002013047207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1124094362Medicaid
MO1124094362Medicaid