Basic Information
| Provider Information | |||||||||
| NPI: | 1780628149 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SANFORD HEALTH OF NORTHERN MINNESOTA | ||||||||
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| OtherOrganizationName: | SANFORD BEMIDJI MAIN CLINIC OUTREACH TO NEILSON PLACE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5074 | ||||||||
| Address2: | |||||||||
| City: | SIOUX FALLS | ||||||||
| State: | SD | ||||||||
| PostalCode: | 571175074 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6053286585 | ||||||||
| FaxNumber: | 6053288311 | ||||||||
| Practice Location | |||||||||
| Address1: | 1300 ANNE ST NW | ||||||||
| Address2: | |||||||||
| City: | BEMIDJI | ||||||||
| State: | MN | ||||||||
| PostalCode: | 566015103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2183335000 | ||||||||
| FaxNumber: | 2183335360 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2006 | ||||||||
| LastUpdateDate: | 10/26/2022 | ||||||||
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| AuthorizedOfficialLastName: | MORRISON | ||||||||
| AuthorizedOfficialFirstName: | TONY | ||||||||
| AuthorizedOfficialMiddleName: | LEE | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT, REVENUE CYCLE | ||||||||
| AuthorizedOfficialTelephone: | 6053288380 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 10/26/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207V00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207X00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207ZP0101X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology | 208600000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | 261QM0801X | N | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.