Healthcare Provider Details

I. General information

NPI: 1023203619
Provider Name (Legal Business Name): SANFORD CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/07/2007
Last Update Date: 11/27/2023
Certification Date: 06/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5019 S WESTERN AVE STE 200
SIOUX FALLS SD
57108-5095
US

IV. Provider business mailing address

PO BOX 5074
SIOUX FALLS SD
57117-5074
US

V. Phone/Fax

Practice location:
  • Phone: 605-328-9700
  • Fax:
Mailing address:
  • Phone: 605-328-8395
  • Fax: 605-328-9401

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number StateNULL
# 6
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number
License Number StateNULL

VIII. Authorized Official

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