Basic Information
| Provider Information | |||||||||
| NPI: | 1982780144 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SANFORD HEALTH NETWORK | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | SANFORD CLINIC SHELDON | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 800 OAK ST | ||||||||
| Address2: | P.O. BOX 10 | ||||||||
| City: | SHELDON | ||||||||
| State: | IA | ||||||||
| PostalCode: | 512011242 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7123245356 | ||||||||
| FaxNumber: | 7123246515 | ||||||||
| Practice Location | |||||||||
| Address1: | 800 OAK ST | ||||||||
| Address2: | |||||||||
| City: | SHELDON | ||||||||
| State: | IA | ||||||||
| PostalCode: | 512011242 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7123245356 | ||||||||
| FaxNumber: | 7123246515 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/31/2006 | ||||||||
| LastUpdateDate: | 10/31/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GUSTAFSON | ||||||||
| AuthorizedOfficialFirstName: | JOEL | ||||||||
| AuthorizedOfficialMiddleName: | MASON | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 7123245356 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SANFORD HEALTH NETWORK | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
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 | 0254656 | 05 | IA | MEDICAID | 0638593 | 05 | IA | MEDICAID |