Basic Information
| Provider Information | |||||||||
| NPI: | 1053389742 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MALLING | ||||||||
| FirstName: | HEIDI | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | ESSENTIA HEALTH DULUTH CLINIC MCL2CRED | ||||||||
| Address2: | 400 EAST THIRD STREET | ||||||||
| City: | DULUTH | ||||||||
| State: | MN | ||||||||
| PostalCode: | 558051951 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2187863146 | ||||||||
| FaxNumber: | 2187228792 | ||||||||
| Practice Location | |||||||||
| Address1: | 523 N 3RD ST | ||||||||
| Address2: | |||||||||
| City: | BRAINERD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 564013054 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2188292861 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/09/2006 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 39579 | MN | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 26036 | OK | N | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 20013750A | 05 | OK | MEDICAID |