Provider Demographics
NPI:1043541147
Name:ROBERT J TRACE JR MD PA
Entity type:Organization
Organization Name:ROBERT J TRACE JR MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:TRACE
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:301-739-2560
Mailing Address - Street 1:121 E ANTIETAM ST
Mailing Address - Street 2:
Mailing Address - City:HAGERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21740-5601
Mailing Address - Country:US
Mailing Address - Phone:301-739-2560
Mailing Address - Fax:301-739-0266
Practice Address - Street 1:121 E ANTIETAM ST
Practice Address - Street 2:
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21740-5601
Practice Address - Country:US
Practice Address - Phone:301-739-2560
Practice Address - Fax:301-739-0266
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-29
Last Update Date:2010-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD22012207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD964111400MDMedicaid
MD964111400MDMedicaid