| Organization Name: | TRACIE M MALLBERG MD PC |
| NPI Number: | 1023282969 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | TRACIE M MALLBERG (PRESIDENT) |
| Mailing Address: | 550 13th Ave E West Fargo |
| State: | ND US |
| Postal Code: | 580783360 |
| Phone Number: | 7013565459 |
| Fax Number: | 7013563764 |
| NPI Enumeration Date: | 04/22/2008 |
| NPI Last Update Date: | 08/01/2008 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 261QP2300X |
| License Number: | 9395 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | ND |
| Taxonomy Type: | Ambulatory Health Care Facilities |
| Taxonomy Classification: | Clinic/Center |
| Taxonomy Specialization: | Primary Care |
| Taxonomy Definition: | |