Provider Demographics
NPI:1700989704
Name:BRANDENBURG, TRACY RENEE (MD)
Entity Type:Individual
Prefix:MRS
First Name:TRACY
Middle Name:RENEE
Last Name:BRANDENBURG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:TRACY
Other - Middle Name:RENEE
Other - Last Name:MCCOMB
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:2919 WILDER RD
Mailing Address - Street 2:
Mailing Address - City:BAY CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48706-9299
Mailing Address - Country:US
Mailing Address - Phone:989-671-5700
Mailing Address - Fax:989-671-5706
Practice Address - Street 1:2919 WILDER RD
Practice Address - Street 2:
Practice Address - City:BAY CITY
Practice Address - State:MI
Practice Address - Zip Code:48706-9299
Practice Address - Country:US
Practice Address - Phone:989-671-5700
Practice Address - Fax:989-671-5706
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2022-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301078893208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4368262Medicaid
MI4368262Medicaid
MIC26008082Medicare ID - Type Unspecified