Basic Information
| Provider Information | |||||||||
| NPI: | 1053335307 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PRINCE | ||||||||
| FirstName: | TRACY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2030 THISTLE HILL DR | ||||||||
| Address2: | |||||||||
| City: | SPRING GROVE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 173621159 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7172259869 | ||||||||
| FaxNumber: | 7172256552 | ||||||||
| Practice Location | |||||||||
| Address1: | 2030 THISTLE HILL DR | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | SPRING GROVE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 173621159 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7172259869 | ||||||||
| FaxNumber: | 7172256552 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2006 | ||||||||
| LastUpdateDate: | 03/17/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | OS010945L | PA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2525814 | 01 | PA | CIGNA | OTHER | 7989331 | 01 | PA | AETNA | OTHER | 50097247 | 01 | PA | CAPITAL BC | OTHER | 1386391 | 01 | PA | HIGHMARK BS | OTHER | 0019165970004 | 05 | PA | MEDICAID | P010738 | 01 | PA | GATEWAY HEALTH PLAN | OTHER |