Healthcare Provider Details

I. General information

NPI: 1891358057
Provider Name (Legal Business Name): PHILIP TRACY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/15/2019
Last Update Date: 06/12/2025
Certification Date: 06/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

593 EDDY ST
PROVIDENCE RI
02903-4923
US

IV. Provider business mailing address

800 WASHINGTON ST
BOSTON MA
02111-1552
US

V. Phone/Fax

Practice location:
  • Phone: 401-793-2920
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number280247
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License NumberMD20544
License Number StateRI
# 3
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License NumberMD20544
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: