Provider Demographics
NPI:1457356958
Name:POWELL, TRACI E (MD)
Entity type:Individual
Prefix:DR
First Name:TRACI
Middle Name:E
Last Name:POWELL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:2944 W 86TH PL
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60652-3830
Mailing Address - Country:US
Mailing Address - Phone:773-471-7795
Mailing Address - Fax:773-471-7796
Practice Address - Street 1:9415 S WESTERN AVE
Practice Address - Street 2:STE 201A
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60620-6230
Practice Address - Country:US
Practice Address - Phone:773-779-9700
Practice Address - Fax:773-779-9732
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-20
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IL2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
H90010Medicare UPIN