Provider Demographics
NPI:1538364393
Name:PETER A TRACE, M.D.
Entity type:Organization
Organization Name:PETER A TRACE, M.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:ALEXANDER
Authorized Official - Last Name:TRACE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:217-243-8455
Mailing Address - Street 1:1600 W WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62650-1136
Mailing Address - Country:US
Mailing Address - Phone:217-243-8455
Mailing Address - Fax:
Practice Address - Street 1:1600 W WALNUT ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:IL
Practice Address - Zip Code:62650-1136
Practice Address - Country:US
Practice Address - Phone:217-243-8455
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-20
Last Update Date:2009-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036048526Medicaid
IL06900105OtherPHAI
IL06900105OtherBLUE CROSS BLUE SHIELD
KY13127OtherGROUP HEALTH PLAN
IL010986OtherHEALTH ALLIANCE
MO127838OtherHEALTHLINK
KY13127OtherGROUP HEALTH PLAN