Basic Information
| Provider Information | |||||||||
| NPI: | 1013188754 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HENDERSON | ||||||||
| FirstName: | TRACEY | ||||||||
| MiddleName: | A. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PERAZONE | ||||||||
| OtherFirstName: | TRACEY | ||||||||
| OtherMiddleName: | ANN | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 200 HYGEIA DRIVE, SUITE 2300 | ||||||||
| Address2: | CCHS PHYSICIAN CONTRACTING | ||||||||
| City: | NEWARK | ||||||||
| State: | DE | ||||||||
| PostalCode: | 197132049 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | |||||||||
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| Practice Location | |||||||||
| Address1: | 4755 OGLETOWN-STANTON ROAD | ||||||||
| Address2: | MAP 1, SUITE 116 | ||||||||
| City: | NEWARK | ||||||||
| State: | DE | ||||||||
| PostalCode: | 197182200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3027334200 | ||||||||
| FaxNumber: | 3027332711 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/21/2008 | ||||||||
| LastUpdateDate: | 06/10/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 258019 | NY | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | C1-0011343 | DE | Y | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.