Provider Demographics
NPI:1255371951
Name:EDWARDS, TRACI M (MD)
Entity type:Individual
Prefix:
First Name:TRACI
Middle Name:M
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6801 DIXIE HWY
Mailing Address - Street 2:SUITE 130
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40258-3913
Mailing Address - Country:US
Mailing Address - Phone:502-937-1717
Mailing Address - Fax:502-935-4921
Practice Address - Street 1:9616 DIXIE HWY
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40272-3440
Practice Address - Country:US
Practice Address - Phone:502-937-1717
Practice Address - Fax:502-935-4921
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2013-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY32447207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64447329Medicaid
KY00546097Medicare Oscar/Certification
KYP00185744Medicare PIN
KY64447329Medicaid