Provider Demographics
NPI:1285708438
Name:SANFORD HEALTH OF NORTHERN MINNESOTA
Entity type:Organization
Organization Name:SANFORD HEALTH OF NORTHERN MINNESOTA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OFFICE MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:JON
Authorized Official - Middle Name:F
Authorized Official - Last Name:BERGQUIST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-333-5514
Mailing Address - Street 1:1300 ANNE ST NW
Mailing Address - Street 2:
Mailing Address - City:BEMIDJI
Mailing Address - State:MN
Mailing Address - Zip Code:56601-5103
Mailing Address - Country:US
Mailing Address - Phone:218-751-5430
Mailing Address - Fax:218-333-5566
Practice Address - Street 1:1300 ANNE ST NW
Practice Address - Street 2:
Practice Address - City:BEMIDJI
Practice Address - State:MN
Practice Address - Zip Code:56601-5103
Practice Address - Country:US
Practice Address - Phone:218-751-5430
Practice Address - Fax:218-333-5566
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-20
Last Update Date:2011-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN330837367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNC04961Medicare UPIN