NPIMap

Individual provider Active NPI

Tracee A Blackburn, PA-C

  • Dermatology Physician
  • Chicago, IL
National Provider Identifier
1396776498
Registry record updated Dec 22, 2016
On this page

Key facts

NPPES NPI Registry
Primary specialty
Dermatology PhysicianTaxonomy code 207N00000X
License
085-002507 Issued in IL
Practice address
1460 North Halsted Street
Suite 505
Chicago, IL 60642
Phone
(312) 266-6462
Fax
(312) 266-6481
NPI assigned
Jul 6, 2006
Last updated
Dec 22, 2016By the provider in NPPES
Sex
Female
Sole proprietor
Yes

NPPES NPI Registry

Updated by the provider on Dec 22, 2016

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Dermatology Physician 207N00000X 085-002507 IL Primary
Pediatric Adolescent Medicine Physician 2080A0000X 085-002507 IL

Addresses

Primary practice location

1460 North Halsted Street
Suite 505
Chicago, IL 60642

Mailing address

1460 North Halsted Street
Suite 505
Chicago, IL 60642
Phone (312) 266-6462

Other names 1

  • Miss Tracee Angela Douse-Dean Former name

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Not listed in the public Medicare enrollment file

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Physician Assistant

State licenses

LicenseStateTypeSpecialty
085-002507ILMDDermatology Physician

Practice roles

OrganizationSpecialtyStatusNew patients
Medical Dermatology Associates of Chicago, LTD Dermatology PastSince Mar 1, 2015 Accepting new patients
Physicians Dermpath Laboratory Past Accepting new patients
Nilam K. Amin, D.O., S.C. Dermatology PastSince Feb 5, 2007 Accepting new patients

Organizations & group practices 3

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1152144000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1482364800000",
    "number": "1396776498",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1460 NORTH HALSTED STREET",
            "address_2": "SUITE 505",
            "city": "CHICAGO",
            "state": "IL",
            "postal_code": "60642",
            "telephone_number": "312-266-6462",
            "fax_number": "312-266-6481"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1460 NORTH HALSTED STREET",
            "address_2": "SUITE 505",
            "city": "CHICAGO",
            "state": "IL",
            "postal_code": "60642",
            "telephone_number": "312-266-6462",
            "fax_number": "312-266-6481"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "BLACKBURN",
        "first_name": "TRACEE",
        "middle_name": "A",
        "name_prefix": "Mrs.",
        "credential": "PA-C",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2006-07-06",
        "last_updated": "2016-12-22",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207N00000X",
            "taxonomy_group": "",
            "desc": "Dermatology",
            "state": "IL",
            "license": "085-002507",
            "primary": true
        },
        {
            "code": "2080A0000X",
            "taxonomy_group": "",
            "desc": "Pediatrics, Adolescent Medicine",
            "state": "IL",
            "license": "085-002507",
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "first_name": "TRACEE",
            "last_name": "DOUSE-DEAN",
            "middle_name": "ANGELA",
            "prefix": "MISS",
            "code": "1",
            "type": "Former Name"
        }
    ]
}

Other providers in Chicago, IL

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 22, 2016; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.