Healthcare Provider Details

I. General information

NPI: 1154976058
Provider Name (Legal Business Name): SARAH MAE TRACEY MS, AT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/07/2019
Last Update Date: 08/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5680 VENTURE DR
DUBLIN OH
43017-2190
US

IV. Provider business mailing address

1143 WIMBELDON BLVD
COLUMBUS OH
43228-9326
US

V. Phone/Fax

Practice location:
  • Phone: 614-355-8736
  • Fax:
Mailing address:
  • Phone: 740-504-6311
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RS0010X
TaxonomySports Medicine (Internal Medicine) Physician
License NumberAT005913
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: