Tracie Fullove, M.D.
Individual provider Active NPI Family Medicine Physician · Fayetteville, AR
NPI 1962865659 · NPPES record last updated Jun 19, 2019
Key facts
- NPI
- 1962865659
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Family Medicine Physician 207Q00000X
- License
- E-11276 (AR)
- Practice address
- 3162 W Martin Luther King Blvd Ste 13-14
Fayetteville, AR 72704-7679 - Phone
- (479) 935-4834
- Fax
- (479) 249-9879
- NPI assigned
- Mar 31, 2016
- Sex
- Female
- Sole proprietor
- Yes
Organizations & group practices 7
Medicare Care Compare profile
- Specialty
- Family Practice
- Education
- University of Mississippi School of Medicine, 2016
- Medicare assignment
- Accepts the Medicare-approved amount as payment in full
- Telehealth
- Offers telehealth services
- Group practices
- Mercy Northwest Arkansas Ambulatory Services, LLC
Practice addresses (Care Compare)
2012 S Promenade Blvd
Rogers, AR 72758-9073
Phone (479) 616-1485
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in AR
- Eligible to order & refer
- Part B services: Yes · DME: Yes · Home health: Yes · Power mobility devices: Yes · Hospice: Yes
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20190726000143 | AR | Practitioner - Family Practice | 2860782554 | Reassigns benefits to 2 organizations |
National Provider Directory
- Medicare enrollment (NPD)
- Yes
- Credentials
- Doctor of Medicine
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| E-11276 | AR | MD | Family Medicine Physician |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Mercy Northwest Arkansas Ambulatory Services LLC | Current |
Accepting new patients | |
| St Francis House Nwa, Inc | Current | Accepting new patients | |
| St Francis House Nwa, Inc | Current |
Accepting new patients | |
| St. Francis House Nwa, Inc. | Current |
Accepting new patients | |
| St. Francis House Nwa, Inc. | Past | Accepting new patients | |
| Mercy Health Northwest Arkansas Communities | Past |
Accepting new patients | |
| St. Francis House Nwa, Inc. | Past | Accepting new patients |
Locations
2012 S Promenade Blvd
Rogers, AR 72758
Phone (479) 616-1485
614 E Emma Ave
Ste 300
Springdale, AR 72764
Phone (479) 751-4898
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Family Medicine Physician | 207Q00000X | E-11276 | AR | Yes |
Addresses
Primary practice location
3162 W Martin Luther King Blvd Ste 13-14
Fayetteville, AR 72704-7679
Mailing address
607 Hampton Cir Apt G
Jackson, MS 39211-2334
NPI Registry JSON
{
"created_epoch": "1459382400000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1560902400000",
"number": "1962865659",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "607 HAMPTON CIR APT G",
"city": "JACKSON",
"state": "MS",
"postal_code": "392112334"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "3162 W MARTIN LUTHER KING BLVD STE 13-14",
"city": "FAYETTEVILLE",
"state": "AR",
"postal_code": "727047679",
"telephone_number": "479-935-4834",
"fax_number": "479-249-9879"
}
],
"practiceLocations": [],
"basic": {
"last_name": "FULLOVE",
"first_name": "TRACIE",
"credential": "M.D.",
"sole_proprietor": "YES",
"sex": "F",
"enumeration_date": "2016-03-31",
"last_updated": "2019-06-19",
"status": "A"
},
"taxonomies": [
{
"code": "207Q00000X",
"taxonomy_group": "",
"desc": "Family Medicine",
"state": "AR",
"license": "E-11276",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Fayetteville, AR
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- James M Fuendeling
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- Daniel C Fulmer
- Gerald Howard Funkhouser Jr.
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- John L Furlow
All providers in Fayetteville, AR · Family Medicine Physician in Arkansas
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jun 19, 2019. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Order and Referring (CMS).
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.