Provider Demographics
NPI:1124122783
Name:SANFORD MEDICAL CENTER FARGO
Entity type:Organization
Organization Name:SANFORD MEDICAL CENTER FARGO
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT, REVENUE CYCLE
Authorized Official - Prefix:
Authorized Official - First Name:TONY
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:MORRISON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-328-8380
Mailing Address - Street 1:4000 28TH AVE S
Mailing Address - Street 2:
Mailing Address - City:MOORHEAD
Mailing Address - State:MN
Mailing Address - Zip Code:56560-7926
Mailing Address - Country:US
Mailing Address - Phone:701-234-2121
Mailing Address - Fax:
Practice Address - Street 1:4000 28TH AVE S
Practice Address - Street 2:
Practice Address - City:MOORHEAD
Practice Address - State:MN
Practice Address - Zip Code:56560
Practice Address - Country:US
Practice Address - Phone:701-234-3250
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-12
Last Update Date:2023-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2602723332B00000X, 3336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1124122783Medicaid
24-17081OtherNCPDP
ND21559Medicaid
82-00338OtherMEDICA
MN1213550039Medicare NSC