Provider Demographics
NPI:1871502740
Name:MALLBERG- SYLVESTER, TRACIE MARIE (MD)
Entity Type:Individual
Prefix:MS
First Name:TRACIE
Middle Name:MARIE
Last Name:MALLBERG- SYLVESTER
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 1:1701 38TH ST S STE 101
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-4499
Mailing Address - Country:US
Mailing Address - Phone:701-356-1500
Mailing Address - Fax:701-356-1596
Practice Address - Street 1:1701 38TH ST S STE 101
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-4499
Practice Address - Country:US
Practice Address - Phone:701-356-1500
Practice Address - Fax:701-356-1596
Is Sole Proprietor?:No
Enumeration Date:2006-08-07
Last Update Date:2021-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN46245207Q00000X
ND9395207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN490K2MAOtherBLUE CROSS BLUE SHIELD
MN156629600Medicaid
MN156629600Medicaid
MN080014227Medicare ID - Type UnspecifiedCLINIC GROUP # C02089
MN080014226Medicare ID - Type UnspecifiedHOSPITAL GROUP # C06037