Healthcare Provider Details

I. General information

NPI: 1083994388
Provider Name (Legal Business Name): SANFORD CLINIC NORTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2011
Last Update Date: 11/27/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1611 ANNE ST NW
BEMIDJI MN
56601-5114
US

IV. Provider business mailing address

1611 ANNE ST NW
BEMIDJI MN
56601-5114
US

V. Phone/Fax

Practice location:
  • Phone: 218-333-2020
  • Fax: 218-333-2019
Mailing address:
  • Phone: 218-333-2020
  • Fax: 218-333-2019

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MARTHA K LECLERC
Title or Position: VP
Credential:
Phone: 701-234-6248