Healthcare Provider Details

I. General information

NPI: 1376527051
Provider Name (Legal Business Name): TRACY B PHILLIPS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/06/2005
Last Update Date: 04/17/2022
Certification Date: 04/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 NE TUDOR RD
LEES SUMMIT MO
64086-5794
US

IV. Provider business mailing address

310 NE TUDOR RD
LEES SUMMIT MO
64086-5794
US

V. Phone/Fax

Practice location:
  • Phone: 816-347-0303
  • Fax: 816-347-0160
Mailing address:
  • Phone: 816-347-0303
  • Fax: 816-347-0160

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number114873
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: