Basic Information
| Provider Information | |||||||||
| NPI: | 1821017880 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SANFORD MEDICAL CENTER | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | SANFORD USD MEDICAL CENTER - GNL ACUTE CARE HOSP | ||||||||
| 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: | 6053286512 | ||||||||
| Practice Location | |||||||||
| Address1: | 1305 W 18TH ST | ||||||||
| Address2: | |||||||||
| City: | SIOUX FALLS | ||||||||
| State: | SD | ||||||||
| PostalCode: | 571050401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6053331000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2006 | ||||||||
| LastUpdateDate: | 08/23/2021 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MORRISON | ||||||||
| AuthorizedOfficialFirstName: | TONY | ||||||||
| AuthorizedOfficialMiddleName: | LEE | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT, REVENUE CYCLE | ||||||||
| AuthorizedOfficialTelephone: | 6053288380 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 10564 | SD | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 300393 | 05 | MN | MEDICAID | 80027 | 01 | BLUE CROSS SD | OTHER | 1429HSI | 01 | BLUE CROSS MN | OTHER | H222 | 01 | MIDLANDS CHOICE | OTHER | 26822 | 01 | SIOUX VALLEY HEALTH PLAN | OTHER | 5500270 | 05 | SD | MEDICAID | 875747000 | 05 | MN | MEDICAID | 0901330 | 05 | IA | MEDICAID | 305267200 | 05 | MN | MEDICAID | 0100270 | 05 | SD | MEDICAID | 5025419 | 01 | MEDICA | OTHER | 604115148 | 05 | MN | MEDICAID |