Basic Information
| Provider Information | |||||||||
| NPI: | 1174803472 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SANFORD CLINIC NORTH | ||||||||
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| OtherOrganizationName: | SANFORD ROGER MARIS CANCER CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 820 4TH ST N | ||||||||
| Address2: | |||||||||
| City: | FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 581024539 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7012346161 | ||||||||
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| Practice Location | |||||||||
| Address1: | 820 4TH ST N | ||||||||
| Address2: | |||||||||
| City: | FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 581024539 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7012346161 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2011 | ||||||||
| LastUpdateDate: | 11/20/2019 | ||||||||
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| AuthorizedOfficialLastName: | LECLERC | ||||||||
| AuthorizedOfficialFirstName: | MARTHA | ||||||||
| AuthorizedOfficialMiddleName: | K | ||||||||
| AuthorizedOfficialTitleorPosition: | VP | ||||||||
| AuthorizedOfficialTelephone: | 7012346248 | ||||||||
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| 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 | 207L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 2080P0207X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Hematology-Oncology | 2085R0001X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology | 207RH0003X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
No ID Information.