Healthcare Provider Details

I. General information

NPI: 1700456837
Provider Name (Legal Business Name): TRACY BARWICK MCINTOSH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2021
Last Update Date: 06/30/2021
Certification Date: 06/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 BROAD ST STE 100
SUMTER SC
29150-4167
US

IV. Provider business mailing address

674 W LIBERTY ST
SUMTER SC
29150-4882
US

V. Phone/Fax

Practice location:
  • Phone: 803-773-5227
  • Fax:
Mailing address:
  • Phone: 803-773-5227
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number25136
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: