Healthcare Provider Details

I. General information

NPI: 1518175488
Provider Name (Legal Business Name): ROSSANA BARACCO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2007
Last Update Date: 10/02/2024
Certification Date: 10/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3901 BEAUBIEN CHILDREN'S HOSPITAL OF MI
DETROIT MI
48201-2119
US

IV. Provider business mailing address

3901 BEAUBIEN ST STE H
DETROIT MI
48201-2119
US

V. Phone/Fax

Practice location:
  • Phone: 313-745-5604
  • Fax: 313-966-0039
Mailing address:
  • Phone: 313-966-8341
  • Fax: 313-966-6121

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0210X
TaxonomyPediatric Nephrology Physician
License Number4301088040
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code2080P0210X
TaxonomyPediatric Nephrology Physician
License Number2024032085
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301088040
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: