Healthcare Provider Details

I. General information

NPI: 1891850327
Provider Name (Legal Business Name): TRACEY L GUSELLE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7901 XERXES AVE S
BLOOMINGTON MN
55431-1253
US

IV. Provider business mailing address

3017 BLOOMINGTON AVE
MINNEAPOLIS MN
55407-1715
US

V. Phone/Fax

Practice location:
  • Phone: 952-888-2024
  • Fax: 952-888-3985
Mailing address:
  • Phone: 612-721-6511
  • Fax: 612-721-6511

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number46198
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: