Provider Demographics
NPI:1194056234
Name:TRACIE D HARVEY MD A MEDICAL CORPORATION
Entity type:Organization
Organization Name:TRACIE D HARVEY MD A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLER
Authorized Official - Prefix:
Authorized Official - First Name:EILEEN
Authorized Official - Middle Name:J
Authorized Official - Last Name:VRIEZE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-946-2801
Mailing Address - Street 1:4067 HARDWICK ST
Mailing Address - Street 2:SUITE 313
Mailing Address - City:LAKEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90712-2350
Mailing Address - Country:US
Mailing Address - Phone:323-233-0425
Mailing Address - Fax:323-432-5177
Practice Address - Street 1:4067 HARDWICK ST
Practice Address - Street 2:SUITE 313
Practice Address - City:LAKEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90712-2350
Practice Address - Country:US
Practice Address - Phone:323-233-0425
Practice Address - Fax:323-432-5177
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-28
Last Update Date:2010-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG830522084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG83052Medicare PIN