Healthcare Provider Details

I. General information

NPI: 1770863078
Provider Name (Legal Business Name): SANFORD MEDICAL CENTER FARGO
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

700 1ST AVE S
FARGO ND
58103-1802
US

IV. Provider business mailing address

700 1ST AVE S
FARGO ND
58103-1802
US

V. Phone/Fax

Practice location:
  • Phone: 701-234-4036
  • Fax:
Mailing address:
  • Phone: 701-234-4036
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number
License Number State

VIII. Authorized Official

Name: MARTHA LECLERC
Title or Position: VICE PRESIDENT
Credential:
Phone: 701-234-6248