Provider Demographics
NPI:1053544759
Name:TRACI A KURTZER MD SC
Entity type:Organization
Organization Name:TRACI A KURTZER MD SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TRACI
Authorized Official - Middle Name:A
Authorized Official - Last Name:KURTZER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-328-0238
Mailing Address - Street 1:636 CHURCH ST STE 217
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-4578
Mailing Address - Country:US
Mailing Address - Phone:847-328-0238
Mailing Address - Fax:
Practice Address - Street 1:636 CHURCH ST STE 217
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-4578
Practice Address - Country:US
Practice Address - Phone:847-328-0238
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-27
Last Update Date:2009-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036091007174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILG55966Medicare UPIN