1851173017 NPI number — TRACY GANEM MS, RDN, CSOWM, LD

Table of content: TRACY GANEM MS, RDN, CSOWM, LD (NPI 1851173017)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1851173017 NPI number — TRACY GANEM MS, RDN, CSOWM, LD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GANEM
Provider First Name:
TRACY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MS, RDN, CSOWM, LD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ROBERTS
Provider Other First Name:
TRACY
Provider Other Middle Name:
GANEM
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MS, RDN, CSOWM, LD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1851173017
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/20/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1318 AROLEN DR SE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HUNTSVILLE
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
35803-2627
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
256-479-3925
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4704 WHITESBURG DR SW STE 200
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HUNTSVILLE
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
35802-1681
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
256-880-4510
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/20/2023

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 133VN1201X , with the licence number:  1175 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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