Provider Demographics
NPI:1699757591
Name:TRACY, ELIZABETH (MD)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:TRACY
Suffix:
Gender:F
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 23340
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63156-3340
Mailing Address - Country:US
Mailing Address - Phone:314-645-3743
Mailing Address - Fax:314-647-7967
Practice Address - Street 1:1027 BELLEVUE AVE
Practice Address - Street 2:SUITE 107
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63117-1851
Practice Address - Country:US
Practice Address - Phone:314-645-3743
Practice Address - Fax:314-647-7967
Is Sole Proprietor?:No
Enumeration Date:2005-11-16
Last Update Date:2012-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR6J71207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO0400404OtherUHC
MO000000010039OtherESSENCE
MO4090137OtherAETNA
MO127483OtherGHP
MO16533OtherBCBS
MOE62302OtherMERCY
MO101209OtherHEALTHLINK
MO16533OtherBCBS
MO047011188Medicare PIN
MO0400404OtherUHC
MO127483OtherGHP