Provider Demographics
NPI:1215909361
Name:ROSENBAUM, TRACY ALISSA (DO)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:ALISSA
Last Name:ROSENBAUM
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19519 HARTFORD ST
Mailing Address - Street 2:
Mailing Address - City:EDISON
Mailing Address - State:GA
Mailing Address - Zip Code:39846-5803
Mailing Address - Country:US
Mailing Address - Phone:229-835-2238
Mailing Address - Fax:229-835-3032
Practice Address - Street 1:19519 HARTFORD ST
Practice Address - Street 2:
Practice Address - City:EDISON
Practice Address - State:GA
Practice Address - Zip Code:39846-5803
Practice Address - Country:US
Practice Address - Phone:229-835-2238
Practice Address - Fax:229-835-3032
Is Sole Proprietor?:No
Enumeration Date:2006-02-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA047145207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA08BBSLVMedicare ID - Type Unspecified
GAH01163Medicare UPIN
GA08BDQDMMedicare ID - Type Unspecified