Basic Information
| Provider Information | |||||||||
| NPI: | 1891861761 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SANFORD MEDICAL CENTER FARGO | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SANFORD HOME CARE LISBON | ||||||||
| 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: | 102 10TH AVE W | ||||||||
| Address2: | |||||||||
| City: | LISBON | ||||||||
| State: | ND | ||||||||
| PostalCode: | 580544365 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7016832214 | ||||||||
| FaxNumber: | 7016832130 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/24/2006 | ||||||||
| LastUpdateDate: | 02/18/2021 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MORRISON | ||||||||
| AuthorizedOfficialFirstName: | TONY | ||||||||
| AuthorizedOfficialMiddleName: | LEE | ||||||||
| AuthorizedOfficialTitleorPosition: | VP, REVENUE CYCLE | ||||||||
| AuthorizedOfficialTelephone: | 6053288380 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | 4014A | ND | Y | Agencies | Home Health |
ID Information
| ID | Type | State | Issuer | Description | 33110 | 05 | ND | MEDICAID | 37866 | 01 | HEALTHPARTNERS | OTHER | 1014621 | 01 | PREFERREDONE | OTHER | 59687 | 05 | ND | MEDICAID | 3434 | 01 | NDBC | OTHER | 5900226 | 01 | MEDICA | OTHER | 7A42HE | 01 | MNBC | OTHER |