Healthcare Provider Details

I. General information

NPI: 1891047056
Provider Name (Legal Business Name): TRACY YOUNG ROTH M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/11/2012
Last Update Date: 02/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 CENTER ST STE 3S
MOBILE AL
36604-1512
US

IV. Provider business mailing address

PO BOX 40480
MOBILE AL
36640-0480
US

V. Phone/Fax

Practice location:
  • Phone: 251-415-1496
  • Fax: 251-415-1450
Mailing address:
  • Phone: 251-415-1496
  • Fax: 251-415-1450

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number19526
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number14783
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: