Basic Information
| Provider Information | |||||||||
| NPI: | 1780813311 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHORT | ||||||||
| FirstName: | TRACEE | ||||||||
| MiddleName: | CHAVAWN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8490 PICARDY AVE | ||||||||
| Address2: | BLDG 200 | ||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708093731 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2252371754 | ||||||||
| FaxNumber: | 2252371722 | ||||||||
| Practice Location | |||||||||
| Address1: | 3401 NORTH BLVD | ||||||||
| Address2: | STE 200-B | ||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708063743 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2253812615 | ||||||||
| FaxNumber: | 2253812638 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/02/2009 | ||||||||
| LastUpdateDate: | 09/23/2014 | ||||||||
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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 | 208D00000X | E-6871 | AR | Y | Allopathic & Osteopathic Physicians | General Practice | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program |
ID Information
| ID | Type | State | Issuer | Description | 324582YUB6 | 01 | LA | MEDICARE PTAN | OTHER | 2347799 | 05 | LA | MEDICAID |