Basic Information
Provider Information | |||||||||
NPI: | 1366468456 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SANFORD CLINIC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | SANFORD PAIN CLINIC | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 5074 | ||||||||
Address2: |   | ||||||||
City: | SIOUX FALLS | ||||||||
State: | SD | ||||||||
PostalCode: | 571175074 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6053286585 | ||||||||
FaxNumber: | 6053286512 | ||||||||
Practice Location | |||||||||
Address1: | 1321 W 22ND ST STE LOWER | ||||||||
Address2: |   | ||||||||
City: | SIOUX FALLS | ||||||||
State: | SD | ||||||||
PostalCode: | 571051502 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6053281990 | ||||||||
FaxNumber: | 6053281991 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/14/2006 | ||||||||
LastUpdateDate: | 03/08/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MORRISON | ||||||||
AuthorizedOfficialFirstName: | TONY | ||||||||
AuthorizedOfficialMiddleName: | LEE | ||||||||
AuthorizedOfficialTitleorPosition: | VP | ||||||||
AuthorizedOfficialTelephone: | 6053288380 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/08/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   | 103T00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist |   | 208VP0000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine |
ID Information
ID | Type | State | Issuer | Description | 281988100 | 05 | MN |   | MEDICAID |