Provider Demographics
NPI:1053902395
Name:TRACY K GILES PA
Entity type:Organization
Organization Name:TRACY K GILES PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:K
Authorized Official - Last Name:GILES
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:207-775-6533
Mailing Address - Street 1:1039 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04103-3628
Mailing Address - Country:US
Mailing Address - Phone:207-775-6533
Mailing Address - Fax:
Practice Address - Street 1:1039 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04103-3628
Practice Address - Country:US
Practice Address - Phone:207-775-6533
Practice Address - Fax:207-775-2702
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-29
Last Update Date:2021-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME115510000Medicaid