MEDICARE: SANFORD MEDICAL CENTER FARGO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332H00000X	Eyewear Supplier

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	801770	OTHER		NDBC
2	4C334BE	OTHER		MNBC

General Provider Information

NPI Number	:	1124184403
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SANFORD MEDICAL CENTER FARGO

Provider Business Mailing Address
First Line	:	PO BOX 2168
Second Line	:
City	:	FARGO
State	:	ND
Zip	:	58107-2168
Country	:	US
Telephone Number	:	701-234-2119
Fax Number	:	701-234-2045

Provider Business Practice Location Address
First Line	:	1234 WASHINGTON AVE STE A
Second Line	:
City	:	DETROIT LAKES
State	:	MN
Zip	:	56501-3906
Country	:	US
Telephone Number	:	218-846-2000
Fax Number	:	701-234-2045

Authorized Official
Title or Position	:	VP, FINANCE
Name	:	TONY LEE MORRISON
Credential	:
Telephone Number	:	605-328-8380

Provider Enumeration Date	:	12/29/2006
Last Update Date	:	08/02/2024

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