Provider Demographics
NPI:1821288333
Name:HAERTLING, TRACY ANN (DO)
Entity Type:Individual
Prefix:DR
First Name:TRACY
Middle Name:ANN
Last Name:HAERTLING
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:710 N NILES AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-1924
Mailing Address - Country:US
Mailing Address - Phone:574-647-1610
Mailing Address - Fax:
Practice Address - Street 1:615 N MICHIGAN ST
Practice Address - Street 2:6 EAST
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46601-1033
Practice Address - Country:US
Practice Address - Phone:574-647-6892
Practice Address - Fax:574-647-6895
Is Sole Proprietor?:No
Enumeration Date:2007-07-31
Last Update Date:2016-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0361233032080P0207X
IN02004056A2080P0207X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0207XAllopathic & Osteopathic PhysiciansPediatricsPediatric Hematology-Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000781399OtherBCBS MEMORIAL CHILDRENS HOSPITAL
IN201085280Medicaid
IN201085280Medicaid