1922031210 NPI number — DR. TRACY JANSEN M.D.

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922031210 NPI number — DR. TRACY JANSEN M.D.

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:

JANSEN

Provider First Name:

TRACY

Provider Middle Name:

Provider Name Prefix Text:

DR.

Provider Name Suffix Text:

Provider Credential Text:

M.D.

Provider Gender Code:

F

Provider Other Organization Name:

Provider Other Organization Name Type Code:

Provider Other Last Name:

Provider Other First Name:

Provider Other Middle Name:

Provider Other Name Prefix Text:

Provider Other Name Suffix Text:

Provider Other Credential Text:

Provider Other Last Name Type Code:

NPI Number:

1922031210

Entity Type Code:

Individual

Replacement NPI:

Last Update Date:

01/24/2011

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

1111 BENFIELD BLVD

Provider Second Line Business Mailing Address:

SUITE 200

Provider Business Mailing Address City Name:

MILLERSVILLE

Provider Business Mailing Address State Name:

MD

Provider Business Mailing Address Postal Code:

21108-3002

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

410-729-5100

Provider Business Mailing Address Fax Number:

410-729-5156

Provider First Line Business Practice Location Address:

24A MAGOTHY BEACH RD

Provider Second Line Business Practice Location Address:

Provider Business Practice Location Address City Name:

PASADENA

Provider Business Practice Location Address State Name:

MD

Provider Business Practice Location Address Postal Code:

21122-4428

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

410-255-2700

Provider Business Practice Location Address Fax Number:

410-437-1962

Provider Enumeration Date:

07/09/2006

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

• Taxonomy code: 207Q00000X , with the licence number:  D0062357 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: 132272 . This is a "JHHC PROVIDER NUMBER" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
• Identifier: 1438610 . This is a "AETNA CAPITATED" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
• Identifier: 3576324 . This is a "CIGNA PIN" identifier . This identifiers is of the category "OTHER".
• Identifier: 646211-03 . This is a "CAREFIRST MD RENDERING" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
• Identifier: 7605-0088 . This is a "CAREFIRST BLUECHOICE" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
• Identifier: 8167140 . This is a "MAMSI PRIMARY CARE" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
• Identifier: 2167140 . This is a "MAMSI SPECIALIST" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
• Identifier: P17639 . This is a "CAREFIRST MD POS" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
• Identifier: P00388727 . This is a "RR MEDICARE" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
• Identifier: 407728800 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
• Identifier: 5221541 . This is a "AETNA FEE FOR SERVICE" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".