Healthcare Provider Details

I. General information

NPI: 1700809373
Provider Name (Legal Business Name): TRACY L GROTRIAN D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2006
Last Update Date: 11/21/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 W CURTIS ROAD FAMILY MEDICINE/CONVENIENT CARE
CHAMPAIGN IL
61822
US

IV. Provider business mailing address

P.O. BOX 6002
URBANA IL
61803-6002
US

V. Phone/Fax

Practice location:
  • Phone: 217-365-6201
  • Fax: 217-326-1234
Mailing address:
  • Phone: 217-326-8300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036110788
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: