Provider Demographics
NPI:1154976058
Name:TRACEY, SARAH MAE (MS, AT, ATC)
Entity type:Individual
Prefix:
First Name:SARAH
Middle Name:MAE
Last Name:TRACEY
Suffix:
Gender:F
Credentials:MS, AT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1143 WIMBELDON BLVD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43228-9326
Mailing Address - Country:US
Mailing Address - Phone:740-504-6311
Mailing Address - Fax:
Practice Address - Street 1:5680 VENTURE DR
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:OH
Practice Address - Zip Code:43017-2190
Practice Address - Country:US
Practice Address - Phone:614-355-8736
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-07
Last Update Date:2019-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAT005913207RS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RS0010XAllopathic & Osteopathic PhysiciansInternal MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
2000035614OtherBOARD OF CERTIFICATION FOR ATHLETIC TRAINERS