Basic Information
| Provider Information | |||||||||
| NPI: | 1497730303 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ANTILL | ||||||||
| FirstName: | TRACEY | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 200993 | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 772160993 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2817841111 | ||||||||
| FaxNumber: | 2817841555 | ||||||||
| Practice Location | |||||||||
| Address1: | 301 MEDIC LN | ||||||||
| Address2: | |||||||||
| City: | ALVIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 775115542 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2813316141 | ||||||||
| FaxNumber: | 2813313316 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/13/2005 | ||||||||
| LastUpdateDate: | 11/30/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | K2308 | TX | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1497730303 | 01 | TX | TRICARE SOUTH | OTHER | 131166408 | 05 | TX | MEDICAID | 8F9296 | 01 | TX | BCBSTX PROV NO | OTHER | 131166409 | 05 | TX | MEDICAID |