Provider Demographics
NPI:1205148673
Name:KREBSBACH, LACEY J (MD)
Entity type:Individual
Prefix:
First Name:LACEY
Middle Name:J
Last Name:KREBSBACH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LACEY
Other - Middle Name:J
Other - Last Name:SAUVAGEAU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 2010
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58122-2484
Mailing Address - Country:US
Mailing Address - Phone:701-234-2000
Mailing Address - Fax:
Practice Address - Street 1:2400 32ND AVE S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-5800
Practice Address - Country:US
Practice Address - Phone:701-234-8880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-13
Last Update Date:2022-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301096906207V00000X
ND13281207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4301096906Medicaid
MI4301096906Medicare PIN
MI4301096906Medicare Oscar/Certification
MI4301096906Medicare NSC
MI4301096906Medicare UPIN