Provider Demographics
NPI:1922031210
Name:JANSEN, TRACY (MD)
Entity type:Individual
Prefix:DR
First Name:TRACY
Middle Name:
Last Name:JANSEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 BENFIELD BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MILLERSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21108-3002
Mailing Address - Country:US
Mailing Address - Phone:410-729-5100
Mailing Address - Fax:410-729-5156
Practice Address - Street 1:24A MAGOTHY BEACH RD
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:MD
Practice Address - Zip Code:21122-4428
Practice Address - Country:US
Practice Address - Phone:410-255-2700
Practice Address - Fax:410-437-1962
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2011-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0062357207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD132272OtherJHHC PROVIDER NUMBER
MD1438610OtherAETNA CAPITATED
3576324OtherCIGNA PIN
MD646211-03OtherCAREFIRST MD RENDERING
MD7605-0088OtherCAREFIRST BLUECHOICE
MD8167140OtherMAMSI PRIMARY CARE
MD2167140OtherMAMSI SPECIALIST
MDP17639OtherCAREFIRST MD POS
MDP00388727OtherRR MEDICARE
MD407728800Medicaid
MD5221541OtherAETNA FEE FOR SERVICE
MDP00388727OtherRR MEDICARE
3576324OtherCIGNA PIN