Provider Demographics
NPI:1679571863
Name:PHILLIPS, TRACY THOMAS (DO)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:THOMAS
Last Name:PHILLIPS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 13554
Mailing Address - Street 2:
Mailing Address - City:MAUMELLE
Mailing Address - State:AR
Mailing Address - Zip Code:72113-0554
Mailing Address - Country:US
Mailing Address - Phone:501-350-8505
Mailing Address - Fax:501-488-1020
Practice Address - Street 1:2001 CLUB MANOR DR STE S
Practice Address - Street 2:
Practice Address - City:MAUMELLE
Practice Address - State:AR
Practice Address - Zip Code:72113-7417
Practice Address - Country:US
Practice Address - Phone:501-734-8085
Practice Address - Fax:501-734-8088
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-12
Last Update Date:2024-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE1018261QP2300X, 207Q00000X
ARE-1018208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR129995003Medicaid
AR2Z0853OtherMEDICARE
AR5K158Medicare PIN