Basic Information
| Provider Information | |||||||||
| NPI: | 1164510608 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SANFORD CLINIC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SANFORD CLINIC TRANSPLANT NEPHROLOGY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1201 S EUCLID AVE STE 201 | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | SIOUX FALLS | ||||||||
| State: | SD | ||||||||
| PostalCode: | 571050434 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6053288100 | ||||||||
| FaxNumber: | 6053288101 | ||||||||
| Practice Location | |||||||||
| Address1: | 1201 S EUCLID AVE STE 201 | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | SIOUX FALLS | ||||||||
| State: | SD | ||||||||
| PostalCode: | 571050434 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6053288100 | ||||||||
| FaxNumber: | 6053288101 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2006 | ||||||||
| LastUpdateDate: | 11/25/2019 | ||||||||
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| AuthorizedOfficialLastName: | GOETSCH | ||||||||
| AuthorizedOfficialFirstName: | STEVE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 6053286940 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology | 208600000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
No ID Information.