Provider Demographics
NPI:1174680052
Name:SANFORD CLINIC NORTH
Entity Type:Organization
Organization Name:SANFORD CLINIC NORTH
Other - Org Name:SANFORD SOUTH UNIVERSITY LABORATORY
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 1:1720 UNIVERSITY DR S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-4940
Practice Address - Country:US
Practice Address - Phone:701-280-4150
Practice Address - Fax:701-280-4938
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-02
Last Update Date:2023-07-31
Deactivation Date:2020-08-05
Deactivation Code:
Reactivation Date:2020-09-18
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
NDN71154Medicare ID - Type Unspecified