Basic Information
| Provider Information | |||||||||
| NPI: | 1093876922 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SANFORD HEALTH OF NORTHERN MINNESOTA | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SANFORD BEMIDJI | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1233 34TH ST NW | ||||||||
| Address2: | |||||||||
| City: | BEMIDJI | ||||||||
| State: | MN | ||||||||
| PostalCode: | 566015112 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2183335000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1233 34TH ST NW | ||||||||
| Address2: | |||||||||
| City: | BEMIDJI | ||||||||
| State: | MN | ||||||||
| PostalCode: | 566015112 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2183335000 | ||||||||
| FaxNumber: | 7012342045 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/13/2006 | ||||||||
| LastUpdateDate: | 11/07/2011 | ||||||||
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| AuthorizedOfficialLastName: | LECLERC | ||||||||
| AuthorizedOfficialFirstName: | MARTHA | ||||||||
| AuthorizedOfficialMiddleName: | K | ||||||||
| AuthorizedOfficialTitleorPosition: | VP | ||||||||
| AuthorizedOfficialTelephone: | 7012346248 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | 7Y46BE | 01 | MNBC | OTHER | 000026 | 01 | NDBC | OTHER | 1028455 | 01 | PREFERRED ONE | OTHER | 185297300 | 05 | MN | MEDICAID |