=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841214749
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TRACEY IRENE MEYER-MCLOONE M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/26/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 515 VALLEY VIEW DR SUITE 103
-----------------------------------------------------
City | MOLINE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61265-6175
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 309-757-1252
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7714 106TH AVE
-----------------------------------------------------
City | COAL VALLEY
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61240-9646
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 309-799-7022
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------