Basic Information
| Provider Information | |||||||||
| NPI: | 1447295134 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SANFORD CLINIC NORTH | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SANFORD WEST FARGO CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1220 SHEYENNE ST | ||||||||
| Address2: | |||||||||
| City: | WEST FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 580782637 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7012344445 | ||||||||
| FaxNumber: | 7012344393 | ||||||||
| Practice Location | |||||||||
| Address1: | 1220 SHEYENNE ST | ||||||||
| Address2: | |||||||||
| City: | WEST FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 580782637 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7012344445 | ||||||||
| FaxNumber: | 7012344393 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2006 | ||||||||
| LastUpdateDate: | 11/20/2019 | ||||||||
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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 | 207V00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 894516100 | 05 | MN | MEDICAID |