Basic Information
| Provider Information | |||||||||
| NPI: | 1578763330 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GULLING-LEFTWICH | ||||||||
| FirstName: | TRACY | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GULLING | ||||||||
| OtherFirstName: | TRACY | ||||||||
| OtherMiddleName: | LYNN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | DO | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 9500 EUCLID AVE | ||||||||
| Address2: | M2-ANNEX | ||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441950001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2164440933 | ||||||||
| FaxNumber: | 2164458530 | ||||||||
| Practice Location | |||||||||
| Address1: | 9500 EUCLID AVE | ||||||||
| Address2: | M2-ANNEX | ||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441950001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2164440933 | ||||||||
| FaxNumber: | 2164458530 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2007 | ||||||||
| LastUpdateDate: | 05/23/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 048593 | CT | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | 34011315 | OH | N | Allopathic & Osteopathic Physicians | Hospitalist | 207R00000X | 34.011315 | OH | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | PENDING | 05 | CT | MEDICAID |