Basic Information
| Provider Information | |||||||||
| NPI: | 1578508198 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SANFORD MEDICAL CENTER FARGO | ||||||||
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| OtherOrganizationName: | SANFORD DIALYSIS DETROIT LAKES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2168 | ||||||||
| Address2: | |||||||||
| City: | FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 581072168 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7012342119 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1234 WASHINGTON AVE STE B | ||||||||
| Address2: | |||||||||
| City: | DETROIT LAKES | ||||||||
| State: | MN | ||||||||
| PostalCode: | 565013906 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2188462200 | ||||||||
| FaxNumber: | 2188462201 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2006 | ||||||||
| LastUpdateDate: | 07/02/2020 | ||||||||
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| AuthorizedOfficialLastName: | MORRISON | ||||||||
| AuthorizedOfficialFirstName: | TONY | ||||||||
| AuthorizedOfficialMiddleName: | LEE | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT, REVENUE CYCLE | ||||||||
| AuthorizedOfficialTelephone: | 6053288380 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 07/02/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0700X | Y | Ambulatory Health Care Facilities | Clinic/Center | End-Stage Renal Disease (ESRD) Treatment |
ID Information
| ID | Type | State | Issuer | Description | 735547500 | 05 | MN | MEDICAID | 012096 | 01 | NDBC | OTHER | 1C18HME | 01 | MNBC | OTHER |