Healthcare Provider Details

I. General information

NPI: 1588056899
Provider Name (Legal Business Name): TRACY STEWART
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/23/2015
Last Update Date: 02/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

611 E MADISON AVE
PONTIAC MI
48340-2935
US

IV. Provider business mailing address

611 E MADISON AVE
PONTIAC MI
48340-2935
US

V. Phone/Fax

Practice location:
  • Phone: 248-805-3643
  • Fax:
Mailing address:
  • Phone: 248-805-3643
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: