Provider Demographics
NPI:1912160219
Name:BLICHFELDT, TRACY C (MD)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:C
Last Name:BLICHFELDT
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 1:705 5TH ST NW STE B
Mailing Address - Street 2:
Mailing Address - City:BEMIDJI
Mailing Address - State:MN
Mailing Address - Zip Code:56601-2933
Mailing Address - Country:US
Mailing Address - Phone:218-333-5000
Mailing Address - Fax:
Practice Address - Street 1:705 5TH ST NW STE B
Practice Address - Street 2:
Practice Address - City:BEMIDJI
Practice Address - State:MN
Practice Address - Zip Code:56601-2933
Practice Address - Country:US
Practice Address - Phone:218-333-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-07
Last Update Date:2014-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI52702207R00000X
MN52750207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1912160219Medicaid
MN110013718Medicare PIN