Provider Demographics
NPI:1124189741
Name:SANFORD MEDICAL CENTER FARGO
Entity Type:Organization
Organization Name:SANFORD MEDICAL CENTER FARGO
Other - Org Name:SANFORD DIALYSIS RED LAKE
Other - Org Type:Doing Business As
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:PO BOX 2168
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58107-2168
Mailing Address - Country:US
Mailing Address - Phone:701-234-2119
Mailing Address - Fax:701-234-2045
Practice Address - Street 1:24760 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:RED LAKE
Practice Address - State:MN
Practice Address - Zip Code:56671
Practice Address - Country:US
Practice Address - Phone:218-679-3117
Practice Address - Fax:218-676-4386
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN632605600Medicaid
ND243534Medicare ID - Type Unspecified