Healthcare Provider Details

I. General information

NPI: 1740499656
Provider Name (Legal Business Name): TRACEY EDAN KRASNOW MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/21/2007
Last Update Date: 05/01/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 BLUE HILLS AVE
HARTFORD CT
06112-1500
US

IV. Provider business mailing address

365 W MOUNTAIN RD
WEST SIMSBURY CT
06092-2910
US

V. Phone/Fax

Practice location:
  • Phone: 860-714-3616
  • Fax:
Mailing address:
  • Phone: 317-696-3757
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number01063613A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number01063613A
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number01063613A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: