Healthcare Provider Details

I. General information

NPI: 1275512113
Provider Name (Legal Business Name): TRACY L NIEMEYER MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/10/2006
Last Update Date: 03/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2375 EDGEWOOD RD SW
CEDAR RAPIDS IA
52404-4736
US

IV. Provider business mailing address

2375 EDGEWOOD RD SW
CEDAR RAPIDS IA
52404-4736
US

V. Phone/Fax

Practice location:
  • Phone: 319-396-1983
  • Fax: 319-396-3183
Mailing address:
  • Phone: 319-396-1983
  • Fax: 319-396-3183

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number33172
License Number StateIA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1275512113
Identifier TypeMEDICAID
Identifier StateIA
Identifier Issuer
# 2
Identifier3175687
Identifier TypeMEDICAID
Identifier StateIA
Identifier Issuer
# 3
Identifier5175687
Identifier TypeMEDICAID
Identifier StateIA
Identifier Issuer
# 4
Identifier080190689
Identifier TypeOTHER
Identifier StateIA
Identifier IssuerRR MEDICARE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: