Provider Demographics
NPI:1588664064
Name:TRACY, RAYMOND D (DO)
Entity type:Individual
Prefix:DR
First Name:RAYMOND
Middle Name:D
Last Name:TRACY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:3944 BRENLOR DRIVE
Mailing Address - Street 2:
Mailing Address - City:HESPERIA
Mailing Address - State:MI
Mailing Address - Zip Code:49421
Mailing Address - Country:US
Mailing Address - Phone:231-854-2999
Mailing Address - Fax:231-854-2998
Practice Address - Street 1:6087 E FILMORE RD
Practice Address - Street 2:
Practice Address - City:WALKERVILLE
Practice Address - State:MI
Practice Address - Zip Code:49459-9344
Practice Address - Country:US
Practice Address - Phone:231-854-7655
Practice Address - Fax:231-854-7704
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-27
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIRT007455207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP00232094OtherRAIL ROAD MEDICARE
MI0855110514OtherBCBSM NURSING HOME
MI4260509Medicaid
MIP00232094OtherRAIL ROAD MEDICARE
MIOP18410Medicare Oscar/Certification