Basic Information
| Provider Information | |||||||||
| NPI: | 1447292826 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SANFORD CLINIC NORTH | ||||||||
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| OtherOrganizationName: | SANFORD HEALTH JAMESTOWN CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 904 5TH AVE NE | ||||||||
| Address2: | |||||||||
| City: | JAMESTOWN | ||||||||
| State: | ND | ||||||||
| PostalCode: | 584013437 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7012534000 | ||||||||
| FaxNumber: | 7012534040 | ||||||||
| Practice Location | |||||||||
| Address1: | 904 5TH AVE NE | ||||||||
| Address2: | |||||||||
| City: | JAMESTOWN | ||||||||
| State: | ND | ||||||||
| PostalCode: | 584013437 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7012534000 | ||||||||
| FaxNumber: | 7012534040 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2006 | ||||||||
| LastUpdateDate: | 11/19/2019 | ||||||||
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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 | 208600000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | 103TP0814X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Psychoanalysis | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 805223900 | 05 | MN | MEDICAID |