Basic Information
| Provider Information | |||||||||
| NPI: | 1346256682 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SANFORD CLINIC NORTH | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SANFORD HEALTH ELLENDALE CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2168 | ||||||||
| Address2: | |||||||||
| City: | FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 581072168 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7012342119 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 141 MAIN STREET | ||||||||
| Address2: | |||||||||
| City: | ELLENDALE | ||||||||
| State: | ND | ||||||||
| PostalCode: | 584367101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7013493331 | ||||||||
| FaxNumber: | 7013493212 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2006 | ||||||||
| LastUpdateDate: | 06/30/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MORRISON | ||||||||
| AuthorizedOfficialFirstName: | TONY | ||||||||
| AuthorizedOfficialMiddleName: | LEE | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT, REVENUE CYCLE | ||||||||
| AuthorizedOfficialTelephone: | 6053288380 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 06/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 12857 | 05 | ND | MEDICAID | 1332001 | 01 | ND | BLUE SHIELD | OTHER | 5133 | 05 | ND | MEDICAID | CF8850 | 01 | RAILROAD MEDICARE | OTHER |