Provider Demographics
NPI:1407878424
Name:SANFORD CLINIC NORTH
Entity Type:Organization
Organization Name:SANFORD CLINIC NORTH
Other - Org Name:SANFORD BEMIDJI EAST CLINIC
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 1:3604 BEMIDJI AVE N
Mailing Address - Street 2:
Mailing Address - City:BEMIDJI
Mailing Address - State:MN
Mailing Address - Zip Code:56601-4333
Mailing Address - Country:US
Mailing Address - Phone:218-333-5111
Mailing Address - Fax:218-333-5458
Practice Address - Street 1:3604 BEMIDJI AVE N
Practice Address - Street 2:
Practice Address - City:BEMIDJI
Practice Address - State:MN
Practice Address - Zip Code:56601-4333
Practice Address - Country:US
Practice Address - Phone:218-333-5111
Practice Address - Fax:218-333-5458
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-25
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN194342100Medicaid