=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770849697
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SANFORD HEALTH OF NORTHERN MINNESOTA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/04/2012
-----------------------------------------------------
Last Update Date | 08/04/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 243 CLARK AVE N
-----------------------------------------------------
City | KELLIHER
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56650-3015
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 218-647-8832
-----------------------------------------------------
Fax | 218-647-8127
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 345 4TH ST NW
-----------------------------------------------------
City | KELLIHER
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56650
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 218-647-8832
-----------------------------------------------------
Fax | 218-647-8127
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VICE PRESIDENT, REVENUE CYCLE
-----------------------------------------------------
Name | TONY LEE MORRISON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 605-328-8380
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------