NPIMap

Organization Active NPI

Tracie M Mallberg MD PC

  • Primary Care Clinic/Center
  • West Fargo, ND
National Provider Identifier
1023282969
Registry record updated Aug 1, 2008
On this page

Key facts

NPPES NPI Registry
Primary specialty
Primary Care Clinic/CenterTaxonomy code 261QP2300X
License
9395 Issued in ND
Legal business name
TRACIE M MALLBERG MD PC
Practice address
550 13TH Ave E
West Fargo, ND 58078-3360
Phone
(701) 356-5459
Fax
(701) 356-3764
NPI assigned
Apr 22, 2008
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 1, 2008

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dr. Tracie M Mallberg, M.D.
Title
President
Phone
(701) 356-5459

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Primary Care Clinic/Center 261QP2300X 9395 ND Primary

Addresses

Primary practice location

550 13TH Ave E
West Fargo, ND 58078-3360

Mailing address

550 13TH Ave E
West Fargo, ND 58078-3360
Phone (701) 356-5459

Other identifiers 1

IdentifierTypeStateIssuer
14788MedicaidND

Other names 1

  • LilyCare Clinic Doing business as

National Provider Directory

National Provider Directory

Locations

550 13th Ave E
West Fargo, ND 58078
Phone (701) 282-2770

Practitioners & affiliated clinicians

Practitioners 14

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

View all 14

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1208822400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1217548800000",
    "number": "1023282969",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "550 13TH AVE E",
            "city": "WEST FARGO",
            "state": "ND",
            "postal_code": "580783360",
            "telephone_number": "701-356-5459",
            "fax_number": "701-356-3764"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "550 13TH AVE E",
            "city": "WEST FARGO",
            "state": "ND",
            "postal_code": "580783360",
            "telephone_number": "701-356-5459",
            "fax_number": "701-356-3764"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "TRACIE M MALLBERG MD PC",
        "organizational_subpart": "NO",
        "enumeration_date": "2008-04-22",
        "last_updated": "2008-08-01",
        "status": "A",
        "authorized_official_last_name": "MALLBERG",
        "authorized_official_first_name": "TRACIE",
        "authorized_official_middle_name": "M",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "701-356-5459",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "M.D."
    },
    "taxonomies": [
        {
            "code": "261QP2300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Primary Care",
            "state": "ND",
            "license": "9395",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "14788",
            "state": "ND"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "LilyCare Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in West Fargo, ND

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 1, 2008; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.