Provider Demographics
NPI:1023282969
Name:TRACIE M MALLBERG MD PC
Entity type:Organization
Organization Name:TRACIE M MALLBERG MD PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TRACIE
Authorized Official - Middle Name:M
Authorized Official - Last Name:MALLBERG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:701-356-5459
Mailing Address - Street 1:550 13TH AVE E
Mailing Address - Street 2:
Mailing Address - City:WEST FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58078-3360
Mailing Address - Country:US
Mailing Address - Phone:701-356-5459
Mailing Address - Fax:701-356-3764
Practice Address - Street 1:550 13TH AVE E
Practice Address - Street 2:
Practice Address - City:WEST FARGO
Practice Address - State:ND
Practice Address - Zip Code:58078-3360
Practice Address - Country:US
Practice Address - Phone:701-356-5459
Practice Address - Fax:701-356-3764
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-22
Last Update Date:2008-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND9395261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND14788Medicaid