MEDICARE: TRACEY L TRGOVAC M.D

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	35075473	OH
2	208000000X	Pediatrics Physician	35.075473	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1043257835
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TRACEY L TRGOVAC M.D

Provider Business Mailing Address
First Line	:	4885 OLENTANGY RIVER RD
Second Line	:	SUITE 110
City	:	COLUMBUS
State	:	OH
Zip	:	43214-1952
Country	:	US
Telephone Number	:	614-268-6555
Fax Number	:	614-457-5706

Provider Business Practice Location Address
First Line	:	4885 OLENTANGY RIVER RD
Second Line	:	SUITE 110
City	:	COLUMBUS
State	:	OH
Zip	:	43214-1952
Country	:	US
Telephone Number	:	614-268-6555
Fax Number	:	614-457-5706

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/01/2006
Last Update Date	:	07/31/2013

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Directions to “ TRACEY L TRGOVAC M.D” Practice Location

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