MEDICARE: UPSTREAM HEALTH SERVICES, P.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	6739A	WY
2	208000000X	Pediatrics Physician	6739A	WY
3	207Q00000X	Family Medicine Physician	6460A	WY

General Provider Information

NPI Number	:	1255716833
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	UPSTREAM HEALTH SERVICES, P.C.

Provider Business Mailing Address
First Line	:	250 N EVARTS ST
Second Line	:
City	:	POWELL
State	:	WY
Zip	:	82435-2718
Country	:	US
Telephone Number	:	307-254-0801
Fax Number	:

Provider Business Practice Location Address
First Line	:	250 N EVARTS ST
Second Line	:
City	:	POWELL
State	:	WY
Zip	:	82435-2718
Country	:	US
Telephone Number	:	307-254-0801
Fax Number	:

Authorized Official
Title or Position	:	CO-OWNER
Name	:	DR. MICHAEL DUANE TRACY
Credential	:	M.D.
Telephone Number	:	307-254-0801

Provider Enumeration Date	:	07/24/2015
Last Update Date	:	07/24/2015

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