Basic Information
Provider Information | |||||||||
NPI: | 1952687295 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SANFORD HEALTH NETWORK | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | SANFORD CHAMBERLAIN CLINIC | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 5074 | ||||||||
Address2: |   | ||||||||
City: | SIOUX FALLS | ||||||||
State: | SD | ||||||||
PostalCode: | 571175074 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6053286585 | ||||||||
FaxNumber: | 6053286512 | ||||||||
Practice Location | |||||||||
Address1: | 300 S BYRON BLVD | ||||||||
Address2: |   | ||||||||
City: | CHAMBERLAIN | ||||||||
State: | SD | ||||||||
PostalCode: | 573259741 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6052345511 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/01/2011 | ||||||||
LastUpdateDate: | 07/10/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MORRISON | ||||||||
AuthorizedOfficialFirstName: | TONY | ||||||||
AuthorizedOfficialMiddleName: | LEE | ||||||||
AuthorizedOfficialTitleorPosition: | VICE PRESIDENT, REVENUE CYCLE | ||||||||
AuthorizedOfficialTelephone: | 6053288380 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | SANFORD HEALTH NETWORK | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/10/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 50302 | SD | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |   | 363A00000X | 50302 | SD | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   | 363L00000X | 50302 | SD | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   | 207Q00000X | 50302 | SD | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   | 207R00000X | 50302 | SD | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207V00000X | 50302 | SD | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |   | 282NC0060X | 50302 | SD | Y |   | Hospitals | General Acute Care Hospital | Critical Access |
No ID Information.