Provider Demographics
NPI:1033152319
Name:EVANS, TRACEY L (MD)
Entity type:Individual
Prefix:
First Name:TRACEY
Middle Name:L
Last Name:EVANS
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 1:101 E OLNEY AVE STE 400
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19120-2470
Mailing Address - Country:US
Mailing Address - Phone:215-456-1825
Mailing Address - Fax:610-645-4456
Practice Address - Street 1:609 W GERMANTOWN PIKE BLDG SUITE280
Practice Address - Street 2:
Practice Address - City:EAST NORRITON
Practice Address - State:PA
Practice Address - Zip Code:19403-4243
Practice Address - Country:US
Practice Address - Phone:484-622-7440
Practice Address - Fax:484-622-7455
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2024-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD419780207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0019113850001Medicaid
PA0019113850001Medicaid
PA059821Medicare PIN