=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942476825
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TESSA MARBURGER M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/01/2008
-----------------------------------------------------
Last Update Date | 06/23/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1500 14TH ST W STE 300
-----------------------------------------------------
City | WILLISTON
-----------------------------------------------------
State | ND
-----------------------------------------------------
Zip | 58801-4079
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 701-774-7500
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1500 14TH ST W STE 300
-----------------------------------------------------
City | WILLISTON
-----------------------------------------------------
State | ND
-----------------------------------------------------
Zip | 58801-4079
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 701-774-7500
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084N0008X
-----------------------------------------------------
Taxonomy Name | Neuromuscular Medicine (Psychiatry & Neurology) Physician
-----------------------------------------------------
License Number | 13818
-----------------------------------------------------
License Number State | ND
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2084N0400X
-----------------------------------------------------
Taxonomy Name | Neurology Physician
-----------------------------------------------------
License Number | MD154672
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 2084N0400X
-----------------------------------------------------
Taxonomy Name | Neurology Physician
-----------------------------------------------------
License Number | 13818
-----------------------------------------------------
License Number State | ND
-----------------------------------------------------