Basic Information
| Provider Information | |||||||||
| NPI: | 1922031210 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JANSEN | ||||||||
| FirstName: | TRACY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1111 BENFIELD BLVD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | MILLERSVILLE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 211083002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4107295100 | ||||||||
| FaxNumber: | 4107295156 | ||||||||
| Practice Location | |||||||||
| Address1: | 24A MAGOTHY BEACH RD | ||||||||
| Address2: | |||||||||
| City: | PASADENA | ||||||||
| State: | MD | ||||||||
| PostalCode: | 211224428 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4102552700 | ||||||||
| FaxNumber: | 4104371962 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/09/2006 | ||||||||
| LastUpdateDate: | 01/24/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | D0062357 | MD | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 132272 | 01 | MD | JHHC PROVIDER NUMBER | OTHER | 1438610 | 01 | MD | AETNA CAPITATED | OTHER | 3576324 | 01 | CIGNA PIN | OTHER | 646211-03 | 01 | MD | CAREFIRST MD RENDERING | OTHER | 7605-0088 | 01 | MD | CAREFIRST BLUECHOICE | OTHER | 8167140 | 01 | MD | MAMSI PRIMARY CARE | OTHER | 2167140 | 01 | MD | MAMSI SPECIALIST | OTHER | P17639 | 01 | MD | CAREFIRST MD POS | OTHER | P00388727 | 01 | MD | RR MEDICARE | OTHER | 407728800 | 05 | MD | MEDICAID | 5221541 | 01 | MD | AETNA FEE FOR SERVICE | OTHER |