Provider Demographics
NPI:1477583664
Name:HOLM, MARY K (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:K
Last Name:HOLM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6001
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58108-6001
Mailing Address - Country:US
Mailing Address - Phone:701-364-3300
Mailing Address - Fax:701-364-8906
Practice Address - Street 1:3000 32ND AVE S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-6132
Practice Address - Country:US
Practice Address - Phone:701-364-8000
Practice Address - Fax:701-364-8078
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND6960207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND0701529OtherMEDICA #
ND587814400Medicaid
NDHP19491OtherHEALTHPARTNERS #
ND0702336OtherMEDICA #
ND6T548HOOtherMNBS #
ND12465OtherNDBS #
ND142015OtherUCARE #
NDDDA9011015539OtherPREFERRED ONE #
ND0701528OtherMEDICA #
ND67D25HOOtherMNBS #
NDND200022OtherLHS #
ND17944OtherNDBS #
ND18142Medicaid
ND13809OtherSIOUX VALLEY #
ND13809OtherSIOUX VALLEY #
ND0702336OtherMEDICA #
ND6T548HOOtherMNBS #
ND142015OtherUCARE #
ND17944Medicare ID - Type UnspecifiedND MEDICARE #