MEDICARE: DR. TRICIA KAYE GIFFORD MD

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	207Q00000X	Family Medicine Physician	36101716	IL
2	207Q00000X	Family Medicine Physician	01063240	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	0004132020	OTHER	IL	BCBS
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	000000991452	OTHER	IN	ANTHEM PIN
5	L76814	OTHER		PIN

General Provider Information

NPI Number	:	1326029158
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TRICIA KAYE GIFFORD MD

Provider Business Mailing Address
First Line	:	PO BOX 775383
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60677-5383
Country	:	US
Telephone Number	:	812-376-5315
Fax Number	:

Provider Business Practice Location Address
First Line	:	4001 W GOELLER BLVD
Second Line	:
City	:	COLUMBUS
State	:	IN
Zip	:	47201-8308
Country	:	US
Telephone Number	:	812-375-3330
Fax Number	:	812-375-3329

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/09/2005
Last Update Date	:	09/06/2024

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