Basic Information
| Provider Information | |||||||||
| NPI: | 1598185597 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SANFORD BISMARCK | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | SANFORD HEALTH SAME DAY SURGERY CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5074 | ||||||||
| Address2: | |||||||||
| City: | SIOUX FALLS | ||||||||
| State: | SD | ||||||||
| PostalCode: | 571175074 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6053286585 | ||||||||
| FaxNumber: | 6053286512 | ||||||||
| Practice Location | |||||||||
| Address1: | 2615 FAIRWAY STREET | ||||||||
| Address2: | |||||||||
| City: | DICKINSON | ||||||||
| State: | ND | ||||||||
| PostalCode: | 58601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7014566000 | ||||||||
| FaxNumber: | 7014566192 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/17/2014 | ||||||||
| LastUpdateDate: | 04/21/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MORRISON | ||||||||
| AuthorizedOfficialFirstName: | TONY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT, REVENUE CYCLE | ||||||||
| AuthorizedOfficialTelephone: | 6053289501 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SANFORD BISMARCK | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/21/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | 8419 | 01 | ND | JOINT COMMISSION | OTHER | 5454 | 01 | ND | AAAASF | OTHER |