Provider Demographics
NPI:1215993159
Name:TRACY, KEVIN PATRICK (MD)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:PATRICK
Last Name:TRACY
Suffix:
Gender:M
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:PO BOX 277827
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-7827
Mailing Address - Country:US
Mailing Address - Phone:864-253-8080
Mailing Address - Fax:
Practice Address - Street 1:1770 SKYLYN DR
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29307-1045
Practice Address - Country:US
Practice Address - Phone:864-582-7892
Practice Address - Fax:864-582-1582
Is Sole Proprietor?:No
Enumeration Date:2006-04-20
Last Update Date:2008-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC14815207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCP00386917OtherMEDICARE RAILROAD
SC148156Medicaid
SC148156Medicaid
SCE69182Medicare UPIN
SC5878670001Medicare NSC
SC8688Medicare PIN