Provider Demographics
NPI:1164440228
Name:VAN SCOY, MICHAEL SANFORD
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:SANFORD
Last Name:VAN SCOY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 44TH ST S STE 201&203
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-7411
Mailing Address - Country:US
Mailing Address - Phone:480-494-2465
Mailing Address - Fax:
Practice Address - Street 1:2000 44TH ST S STE 201&203
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-7411
Practice Address - Country:US
Practice Address - Phone:218-786-8364
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2024-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN37704207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32057300Medicaid
MN713727300Medicaid
WI32057300Medicaid
MN119002113Medicare PIN