Healthcare Provider Details

I. General information

NPI: 1588664064
Provider Name (Legal Business Name): RAYMOND D TRACY D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/27/2005
Last Update Date: 02/06/2024
Certification Date: 02/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6087 E FILMORE RD
WALKERVILLE MI
49459-9344
US

IV. Provider business mailing address

3944 BRENLOR DRIVE
HESPERIA MI
49421
US

V. Phone/Fax

Practice location:
  • Phone: 231-854-7655
  • Fax: 231-854-7704
Mailing address:
  • Phone: 231-854-2999
  • Fax: 231-854-2998

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License NumberRT007455
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: