Healthcare Provider Details

I. General information

NPI: 1255485231
Provider Name (Legal Business Name): TRACY L KEDIAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2007
Last Update Date: 09/26/2022
Certification Date: 09/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

279 LINCOLN ST
WORCESTER MA
01605-2120
US

IV. Provider business mailing address

PO BOX 415348
BOSTON MA
02241-5348
US

V. Phone/Fax

Practice location:
  • Phone: 508-334-8830
  • Fax: 508-334-8810
Mailing address:
  • Phone: 888-225-8885
  • Fax: 508-334-1977

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number159787
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: