MEDICARE: TRACEE L WOJTKOWSKI M.D.

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	38045	KY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000000245568	OTHER	KY	BLUE SHIELD

General Provider Information

NPI Number	:	1902889033
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TRACEE L WOJTKOWSKI M.D.

Provider Business Mailing Address
First Line	:	6801 DIXIE HWY
Second Line	:	SUITE 127
City	:	LOUISVILLE
State	:	KY
Zip	:	40258-3913
Country	:	US
Telephone Number	:	502-935-5633
Fax Number	:	502-935-5706

Provider Business Practice Location Address
First Line	:	6801 DIXIE HWY
Second Line	:	SUITE 127
City	:	LOUISVILLE
State	:	KY
Zip	:	40258-3913
Country	:	US
Telephone Number	:	502-935-5633
Fax Number	:	502-935-5706

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

Provider Enumeration Date	:	11/22/2005
Last Update Date	:	05/12/2009

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