Provider Demographics
NPI:1093876922
Name:SANFORD HEALTH OF NORTHERN MINNESOTA
Entity Type:Organization
Organization Name:SANFORD HEALTH OF NORTHERN MINNESOTA
Other - Org Name:SANFORD BEMIDJI
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
Authorized Official - First Name:MARTHA
Authorized Official - Middle Name:K
Authorized Official - Last Name:LECLERC
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-234-6248
Mailing Address - Street 1:1233 34TH ST NW
Mailing Address - Street 2:
Mailing Address - City:BEMIDJI
Mailing Address - State:MN
Mailing Address - Zip Code:56601-5112
Mailing Address - Country:US
Mailing Address - Phone:218-333-5000
Mailing Address - Fax:
Practice Address - Street 1:1233 34TH ST NW
Practice Address - Street 2:
Practice Address - City:BEMIDJI
Practice Address - State:MN
Practice Address - Zip Code:56601-5112
Practice Address - Country:US
Practice Address - Phone:218-333-5000
Practice Address - Fax:701-234-2045
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2011-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
7Y46BEOtherMNBC
000026OtherNDBC
1028455OtherPREFERRED ONE
MN185297300Medicaid
MN490000032Medicare ID - Type Unspecified
ND353507Medicare Oscar/Certification