Provider Demographics
NPI:1528078540
Name:TRAYCOFF, ROGER B (MD)
Entity type:Individual
Prefix:
First Name:ROGER
Middle Name:B
Last Name:TRAYCOFF
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 500
Mailing Address - Street 2:
Mailing Address - City:CHATHAM
Mailing Address - State:IL
Mailing Address - Zip Code:62629-0500
Mailing Address - Country:US
Mailing Address - Phone:217-670-2424
Mailing Address - Fax:217-670-2809
Practice Address - Street 1:2901 OLD JACKSONVILLE RD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62704-7437
Practice Address - Country:US
Practice Address - Phone:217-698-9722
Practice Address - Fax:217-391-0392
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2011-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036051951207R00000X, 207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILCATERPILLAROther6394P
IL036051951OtherIL STATE LICENSE
IL194883OtherPERSONAL CARE
IL14D0949277OtherCLIA
IL08421024OtherBC/BS
IL206164OtherHEALTHLINK
IL020057300OtherBLACK LUNG
ILCD7143OtherRR MEDICARE GROUP
ILP00144541OtherRR MEDICARE PIN
IL029224OtherHEALTH ALLIANCE
IL036051951Medicaid
IL133586700OtherACS-OWCP
IL08421024OtherBC/BS