Healthcare Provider Details

I. General information

NPI: 1023282969
Provider Name (Legal Business Name): TRACIE M MALLBERG MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/22/2008
Last Update Date: 08/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 13TH AVE E
WEST FARGO ND
58078-3360
US

IV. Provider business mailing address

550 13TH AVE E
WEST FARGO ND
58078-3360
US

V. Phone/Fax

Practice location:
  • Phone: 701-356-5459
  • Fax: 701-356-3764
Mailing address:
  • Phone: 701-356-5459
  • Fax: 701-356-3764

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number9395
License Number StateND

VIII. Authorized Official

Name: DR. TRACIE M MALLBERG
Title or Position: PRESIDENT
Credential: M.D.
Phone: 701-356-5459