Healthcare Provider Details

I. General information

NPI: 1871502740
Provider Name (Legal Business Name): TRACIE MARIE MALLBERG- SYLVESTER M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/07/2006
Last Update Date: 10/28/2021
Certification Date: 10/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 38TH ST S STE 101
FARGO ND
58103-4499
US

IV. Provider business mailing address

1701 38TH ST S STE 101
FARGO ND
58103-4499
US

V. Phone/Fax

Practice location:
  • Phone: 701-356-1500
  • Fax: 701-356-1596
Mailing address:
  • Phone: 701-356-1500
  • Fax: 701-356-1596

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number46245
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number9395
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: