Basic Information
Provider Information | |||||||||
NPI: | 1316004369 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SANFORD HEALTH OF NORTHERN MINNESOTA | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | SANFORD BEMIDJI | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 720 4TH ST N | ||||||||
Address2: | PO BOX 2010 | ||||||||
City: | FARGO | ||||||||
State: | ND | ||||||||
PostalCode: | 581220605 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2183335000 | ||||||||
FaxNumber: | 7012342045 | ||||||||
Practice Location | |||||||||
Address1: | 1233 34TH ST NW | ||||||||
Address2: |   | ||||||||
City: | BEMIDJI | ||||||||
State: | MN | ||||||||
PostalCode: | 566015112 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2183335000 | ||||||||
FaxNumber: | 7012342045 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/02/2007 | ||||||||
LastUpdateDate: | 11/03/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | LECLERC | ||||||||
AuthorizedOfficialFirstName: | MARTHA | ||||||||
AuthorizedOfficialMiddleName: | K | ||||||||
AuthorizedOfficialTitleorPosition: | VP | ||||||||
AuthorizedOfficialTelephone: | 7012346248 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QX0203X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Oncology, Radiation |
ID Information
ID | Type | State | Issuer | Description | 939646200 | 05 | MN |   | MEDICAID | 1C19HME | 01 |   | MNBC | OTHER |