Basic Information
| Provider Information | |||||||||
| NPI: | 1174556591 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SANFORD CLINIC NORTH | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SANFORD MOORHEAD CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1301 8TH ST S | ||||||||
| Address2: | |||||||||
| City: | MOORHEAD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 565603604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7012343200 | ||||||||
| FaxNumber: | 7012343286 | ||||||||
| Practice Location | |||||||||
| Address1: | 1301 8TH ST S | ||||||||
| Address2: | |||||||||
| City: | MOORHEAD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 565603604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7012343200 | ||||||||
| FaxNumber: | 7012343286 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/09/2006 | ||||||||
| LastUpdateDate: | 11/02/2011 | ||||||||
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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 | 103T00000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207RG0300X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine | 208000000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 2084P0800X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 907519400 | 05 | MN | MEDICAID |