Provider Demographics
NPI:1770592636
Name:ELLINGTON, TRACY (DPM)
Entity type:Individual
Prefix:DR
First Name:TRACY
Middle Name:
Last Name:ELLINGTON
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 DAKOTA
Mailing Address - Street 2:SUITE B, FOX VALLEY PODIATRY OF MCHENRY COUNTRY
Mailing Address - City:CRYSTAL LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60012
Mailing Address - Country:US
Mailing Address - Phone:815-788-8680
Mailing Address - Fax:815-788-8746
Practice Address - Street 1:650 DAKOTA
Practice Address - Street 2:SUITE B, FOX VALLEY PODIATRY OF MCHENRY COUNTRY
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60012
Practice Address - Country:US
Practice Address - Phone:815-788-8680
Practice Address - Fax:815-788-8746
Is Sole Proprietor?:No
Enumeration Date:2006-08-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL213E00000X, 213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Not Answered213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
U93569Medicare UPIN