=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023282969
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TRACIE M MALLBERG MD PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/22/2008
-----------------------------------------------------
Last Update Date | 08/01/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 550 13TH AVE E
-----------------------------------------------------
City | WEST FARGO
-----------------------------------------------------
State | ND
-----------------------------------------------------
Zip | 58078-3360
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 701-356-5459
-----------------------------------------------------
Fax | 701-356-3764
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 550 13TH AVE E
-----------------------------------------------------
City | WEST FARGO
-----------------------------------------------------
State | ND
-----------------------------------------------------
Zip | 58078-3360
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 701-356-5459
-----------------------------------------------------
Fax | 701-356-3764
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. TRACIE M MALLBERG
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 701-356-5459
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number | 9395
-----------------------------------------------------
License Number State | ND
-----------------------------------------------------