Provider Demographics
NPI:1518901602
Name:THOMAS, TRACEY S (DO)
Entity type:Individual
Prefix:
First Name:TRACEY
Middle Name:S
Last Name:THOMAS
Suffix:
Gender:F
Credentials:DO
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 746725
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-6725
Mailing Address - Country:US
Mailing Address - Phone:312-733-9730
Mailing Address - Fax:773-866-8014
Practice Address - Street 1:4221 ASHEVILLE HWY
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37914-3508
Practice Address - Country:US
Practice Address - Phone:865-392-7264
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2024-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34.009991207Q00000X
TN5634207Q00000X
KY02969207Q00000X
WV2438207Q00000X
NC2012-02056207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV00799629OtherRR MEDICARE
KY64124860Medicaid
OH2754318Medicaid
KY000000484080OtherANTHEM BCBS
WV3810016933Medicaid
WV00799629OtherRR MEDICARE
KY0641227Medicare PIN
KY000000484080OtherANTHEM BCBS
WV4282091Medicare PIN