Provider Demographics
NPI:1619990603
Name:SANFORD CLINIC
Entity Type:Organization
Organization Name:SANFORD CLINIC
Other - Org Name:SANFORD CLINIC FAMILY MEDICINE HARRISBURG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:STEVE
Authorized Official - Middle Name:
Authorized Official - Last Name:GOETSCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-328-6940
Mailing Address - Street 1:410 N CLIFF AVE
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:SD
Mailing Address - Zip Code:57032-2253
Mailing Address - Country:US
Mailing Address - Phone:605-743-5199
Mailing Address - Fax:605-743-5378
Practice Address - Street 1:410 N CLIFF AVE
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:SD
Practice Address - Zip Code:57032-2253
Practice Address - Country:US
Practice Address - Phone:605-743-5199
Practice Address - Fax:605-743-5378
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-25
Last Update Date:2008-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SDS40853Medicare PIN
SDCH8874Medicare PIN