MEDICARE: MARIE ELAINE TRACE 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	208000000X	Pediatrics Physician	35.142487	OH
2	2080P0006X	Developmental - Behavioral Pediatrics Physician	35.142487	OH
3	2080P0006X	Developmental - Behavioral Pediatrics Physician	41605	KY

General Provider Information

NPI Number	:	1659416667
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARIE ELAINE TRACE MD

Provider Business Mailing Address
First Line	:	407 LOOKOUT CT
Second Line	:
City	:	AVON LAKE
State	:	OH
Zip	:	44012-2462
Country	:	US
Telephone Number	:	502-235-4428
Fax Number	:

Provider Business Practice Location Address
First Line	:	1900 RICHMOND RD
Second Line	:
City	:	LEXINGTON
State	:	KY
Zip	:	40502-1204
Country	:	US
Telephone Number	:	859-218-1900
Fax Number	:	859-218-7573

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

Provider Enumeration Date	:	02/20/2007
Last Update Date	:	04/29/2024

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Directions to “ MARIE ELAINE TRACE MD” Practice Location

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