Healthcare Provider Details

I. General information

NPI: 1912241654
Provider Name (Legal Business Name): TRACY MIDDLEBROOKS, MD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/19/2012
Last Update Date: 11/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2315 CENTRAL AVE
AUGUSTA GA
30904-6272
US

IV. Provider business mailing address

2315 CENTRAL AVE
AUGUSTA GA
30904-6272
US

V. Phone/Fax

Practice location:
  • Phone: 706-667-0070
  • Fax:
Mailing address:
  • Phone: 706-667-0070
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number021986
License Number StateGA

VIII. Authorized Official

Name: TRACY MIDDLEBROOKS
Title or Position: OWNER
Credential: MD
Phone: 706-667-0070