Provider Demographics
NPI:1447276316
Name:GALLAGHER, TRACY LYNN (MD)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:LYNN
Last Name:GALLAGHER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 19070
Mailing Address - Street 2:PREVEA HEALTH
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54307-9070
Mailing Address - Country:US
Mailing Address - Phone:920-496-4700
Mailing Address - Fax:920-431-1967
Practice Address - Street 1:1821 S WEBSTER AVE
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-2253
Practice Address - Country:US
Practice Address - Phone:920-496-4700
Practice Address - Fax:920-431-1967
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2008-07-17
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
WI36930207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32327700Medicaid
WI32327700Medicaid
G50963Medicare UPIN