Provider Demographics
NPI:1902091721
Name:TRACY S FANSLER MD LLC
Entity Type:Organization
Organization Name:TRACY S FANSLER MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:S
Authorized Official - Last Name:FANSLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:727-584-9500
Mailing Address - Street 1:11200 SEMINOLE BLVD STE 210
Mailing Address - Street 2:
Mailing Address - City:LARGO
Mailing Address - State:FL
Mailing Address - Zip Code:33778-3239
Mailing Address - Country:US
Mailing Address - Phone:727-584-9500
Mailing Address - Fax:727-440-9178
Practice Address - Street 1:12955 SEMINOLE BLVD
Practice Address - Street 2:
Practice Address - City:LARGO
Practice Address - State:FL
Practice Address - Zip Code:33778-2399
Practice Address - Country:US
Practice Address - Phone:727-584-9500
Practice Address - Fax:727-584-9502
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-14
Last Update Date:2019-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL261667000Medicaid
FLK6258Medicare PIN