Basic Information
| Provider Information | |||||||||
| NPI: | 1477583664 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HOLM | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 6001 | ||||||||
| Address2: | |||||||||
| City: | FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 581086001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7013643300 | ||||||||
| FaxNumber: | 7013648906 | ||||||||
| Practice Location | |||||||||
| Address1: | 3000 32ND AVE S | ||||||||
| Address2: | |||||||||
| City: | FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 581036132 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7013648000 | ||||||||
| FaxNumber: | 7013648078 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/03/2006 | ||||||||
| LastUpdateDate: | 10/26/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/26/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 6960 | ND | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 0701529 | 01 | ND | MEDICA # | OTHER | 587814400 | 05 | ND | MEDICAID | HP19491 | 01 | ND | HEALTHPARTNERS # | OTHER | 0702336 | 01 | ND | MEDICA # | OTHER | 6T548HO | 01 | ND | MNBS # | OTHER | 12465 | 01 | ND | NDBS # | OTHER | 142015 | 01 | ND | UCARE # | OTHER | DDA9011015539 | 01 | ND | PREFERRED ONE # | OTHER | 0701528 | 01 | ND | MEDICA # | OTHER | 67D25HO | 01 | ND | MNBS # | OTHER | ND200022 | 01 | ND | LHS # | OTHER | 17944 | 01 | ND | NDBS # | OTHER | 18142 | 05 | ND | MEDICAID | 13809 | 01 | ND | SIOUX VALLEY # | OTHER |