Healthcare Provider Details

I. General information

NPI: 1669524351
Provider Name (Legal Business Name): SANFORD BISMARCK
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/16/2007
Last Update Date: 04/16/2021
Certification Date: 04/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1531 W VILLARD ST STE A
DICKINSON ND
58601-4657
US

IV. Provider business mailing address

2603 E BROADWAY AVE
BISMARCK ND
58501-5107
US

V. Phone/Fax

Practice location:
  • Phone: 701-225-7575
  • Fax:
Mailing address:
  • Phone: 701-323-8307
  • Fax: 701-323-5867

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QX0100X
TaxonomyOccupational Medicine Clinic/Center
License Number261QX0100X
License Number StateND

VIII. Authorized Official

Name: TONY LEE MORRISON
Title or Position: VICE PRESIDENT, REVENUE CYCLE
Credential:
Phone: 605-328-8380