Basic Information
Provider Information | |||||||||
NPI: | 1396764254 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SANFORD CLINIC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | SANFORD HEALTH PSYCHIATRY & PSYCHOLOGY 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: | 6053287177 | ||||||||
Practice Location | |||||||||
Address1: | 2400 W 49TH ST | ||||||||
Address2: |   | ||||||||
City: | SIOUX FALLS | ||||||||
State: | SD | ||||||||
PostalCode: | 571056581 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6053128700 | ||||||||
FaxNumber: | 6053128701 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/19/2006 | ||||||||
LastUpdateDate: | 10/13/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MORRISON | ||||||||
AuthorizedOfficialFirstName: | TONY | ||||||||
AuthorizedOfficialMiddleName: | LEE | ||||||||
AuthorizedOfficialTitleorPosition: | VICE PRESIDENT, REVENUE CYCLE | ||||||||
AuthorizedOfficialTelephone: | 6053288380 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/13/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0804X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry | 363L00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   | 363LP0808X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health | 103T00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist |   |
ID Information
ID | Type | State | Issuer | Description | 0537886 | 05 | IA |   | MEDICAID | 682698900 | 05 | MN |   | MEDICAID |