Basic Information
| Provider Information | |||||||||
| NPI: | 1740282136 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TRACY | ||||||||
| FirstName: | SHERRILL | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 133 PLEASANT STREET | ||||||||
| Address2: | |||||||||
| City: | BERLIN | ||||||||
| State: | NH | ||||||||
| PostalCode: | 03570 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6037522040 | ||||||||
| FaxNumber: | 6037527797 | ||||||||
| Practice Location | |||||||||
| Address1: | 2 BROADWAY STREET | ||||||||
| Address2: | |||||||||
| City: | GORHAM | ||||||||
| State: | NH | ||||||||
| PostalCode: | 03581 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6034662741 | ||||||||
| FaxNumber: | 6034662953 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2005 | ||||||||
| LastUpdateDate: | 01/15/2015 | ||||||||
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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 | 207Q00000X | 6910 | NH | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 6910 | 01 | NH | STATE LICENSE # | OTHER | 81083242 | 05 | NH | MEDICAID | P00120775 | 01 | RAILROAD MEDICARE | OTHER | 5635115001 | 01 | NH | CIGNA HEALTHCARE | OTHER | AT2218370 | 01 | FEDERAL DEA# | OTHER | 0104864YPNH02 | 01 | NH | ANTHEM BC/BS | OTHER |