Provider Demographics
NPI:1518095124
Name:PULLIAM, TRACY (MD)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:PULLIAM
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 1814
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:AL
Mailing Address - Zip Code:35758-5410
Mailing Address - Country:US
Mailing Address - Phone:256-429-5196
Mailing Address - Fax:256-429-4573
Practice Address - Street 1:1 HOSPITAL DRIVE SE
Practice Address - Street 2:CRESTWOOD HOSPITAL
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35801
Practice Address - Country:US
Practice Address - Phone:256-429-5196
Practice Address - Fax:256-429-4573
Is Sole Proprietor?:No
Enumeration Date:2007-03-02
Last Update Date:2010-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL26489207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL510I110424OtherMEDICARE
AL109222Medicaid
AL515-97252OtherBCBS OF ALABAMA
AL51539247OtherBCBS OF ALABAMA
AL051558692Medicaid
ALG58939Medicare UPIN
AL051558692Medicaid