MEDICARE: SANFORD MEDICAL CENTER FARGO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QE0700X	End-Stage Renal Disease (ESRD) Treatment Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	012096	OTHER	NDBC
3	1C18HME	OTHER	MNBC

General Provider Information

NPI Number	:	1578508198
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SANFORD MEDICAL CENTER FARGO

Provider Business Mailing Address
First Line	:	PO BOX 2168
Second Line	:
City	:	FARGO
State	:	ND
Zip	:	58107-2168
Country	:	US
Telephone Number	:	701-234-2119
Fax Number	:

Provider Business Practice Location Address
First Line	:	1234 WASHINGTON AVE STE B
Second Line	:
City	:	DETROIT LAKES
State	:	MN
Zip	:	56501-3906
Country	:	US
Telephone Number	:	218-846-2200
Fax Number	:	218-846-2201

Authorized Official
Title or Position	:	VICE PRESIDENT, REVENUE CYCLE
Name	:	TONY LEE MORRISON
Credential	:
Telephone Number	:	605-328-8380

Provider Enumeration Date	:	06/18/2006
Last Update Date	:	07/02/2020

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