Provider Demographics
NPI:1295848521
Name:SANFORD CLINIC
Entity type:Organization
Organization Name:SANFORD CLINIC
Other - Org Name:<UNAVAIL>
Other - Org Type:
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:PO BOX 5074
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57118-5074
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1205 S. GRANGE AVE
Practice Address - Street 2:STE 201
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105-0414
Practice Address - Country:US
Practice Address - Phone:605-328-8100
Practice Address - Fax:605-328-8101
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-17
Last Update Date:2024-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0537886Medicaid
MN284988100Medicaid
SDCH8874Medicare PIN
IA0537886Medicaid
MN284988100Medicaid