Healthcare Provider Details

I. General information

NPI: 1538486295
Provider Name (Legal Business Name): ANTHONY JOSEPH TRACEY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/21/2010
Last Update Date: 10/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

725 IRVING AVE SUITE 403
SYRACUSE NY
13210-2306
US

IV. Provider business mailing address

251 SALINA MEADOWS PKWY STE 100
SYRACUSE NY
13212-4516
US

V. Phone/Fax

Practice location:
  • Phone: 315-464-6060
  • Fax: 315-464-2879
Mailing address:
  • Phone: 315-464-2000
  • Fax: 315-464-2010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2088P0231X
TaxonomyPediatric Urology Physician
License Number40393
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2088P0231X
TaxonomyPediatric Urology Physician
License Number295550
License Number StateNY
# 4
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number295550
License Number StateNY
# 5
Primary TaxonomyN
Taxonomy Code2088P0231X
TaxonomyPediatric Urology Physician
License Number073861
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: