Basic Information
Provider Information | |||||||||
NPI: | 1942415468 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SANFORD MEDICAL CENTER FARGO | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | SANFORD MEDICAL CENTER FARGO | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 2168 | ||||||||
Address2: |   | ||||||||
City: | FARGO | ||||||||
State: | ND | ||||||||
PostalCode: | 581072168 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6053286585 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 801 BROADWAY N | ||||||||
Address2: |   | ||||||||
City: | FARGO | ||||||||
State: | ND | ||||||||
PostalCode: | 581023641 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7012346303 | ||||||||
FaxNumber: | 7012347054 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/10/2007 | ||||||||
LastUpdateDate: | 07/10/2020 | ||||||||
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: | 07/10/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3416A0800X | 395 | MN | N |   | Transportation Services | Ambulance | Air Transport | 3416A0800X | 602 | ND | Y |   | Transportation Services | Ambulance | Air Transport |
ID Information
ID | Type | State | Issuer | Description | 9020442 | 05 | SD |   | MEDICAID | 721 | 01 |   | PREFERRED ONE | OTHER | 735547500 | 05 | MN |   | MEDICAID | 1466HLU | 01 |   | MNBC | OTHER | 23581 | 01 |   | NDBC | OTHER | 5017664 | 01 |   | MEDICA | OTHER | 50794 | 05 | ND |   | MEDICAID |