Sanford Medical Center Fargo
Organization Active NPI Rural Health Clinic/Center · Forman, ND
NPI 1073520003 · NPPES record last updated Nov 29, 2022
Key facts
- NPI
- 1073520003
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Rural Health Clinic/Center 261QR1300X
- Legal business name
- SANFORD MEDICAL CENTER FARGO
- Practice address
- 336 Main Street
Forman, ND 58032-0184 - Phone
- (701) 724-3221
- Fax
- (701) 724-3222
- NPI assigned
- Aug 2, 2006
- Organization subpart
- No
Authorized official
- Name
- Tony Lee Morrison
- Title
- Vice President, Revenue Cycle
- Phone
- (605) 328-8380
Owners & managing parties with NPI records 1
-
Maria C Bell, M.D.
Other NPIs on the same Medicare enrollment 5
Facilities with the same owner 42
Practitioners 99
-
Usman Ali, M.D
-
McKenzie Burke, PA-C
-
Steven Lin Condon, FNP
-
Daniel Deutsch, PA-C
-
Mikenzie Eckroth, LCSW
-
Oluwaseun Emmanuel Fashanu, MD, MPH
-
Brandon Fisher, MD
-
Jason So Go, MD
-
Alli Ann Greff, DNAP, CRNA
-
Eric L Harry, PAC
-
Larry Alan Hendricks, PA-C
-
Rachel Ann Hicks, LAC, LBSW
-
Ryan Holmvig, CRNA
-
Mary Isom, PA-C
-
Russell Andrew Kauffman, P.A.
-
Kendra Jo Kisner, MS, RDN, LRD
-
Melissa Leckie, NP
Laboratory certificates & supplier records
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 35D0408194 | Sanford Health Forman Clinic | Certificate of waiver | Feb 29, 2028 |
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled (2 enrollments) in ND
Rural health clinic certification: CCN 353847
- Legal name
- SANFORD MEDICAL CENTER FARGO
- Doing business as
- SANFORD HEALTH FORMAN CLINIC
- Certification status
- Active
- Provider type (POS)
- Rural health clinic
- Participating since
- Jul 1, 1994
- Last certification
- May 17, 2021
- Ownership / control type
- 2B
- Most recent change of ownership
- Jul 1, 2010 (2 total)
- Organization structure
- Corporation · Proprietary
- Enrollment address
- 336 Main Street
Sanford Healthforman Clinic
Forman, ND 58032-0184
All disclosed owners & managing parties 21
| Name | Role | Since | Share |
|---|---|---|---|
| Mark Allen Lundeen |
Corporate Director | Dec 4, 2014 | |
| Maria Caroline Bell |
Corporate Director |
Aug 1, 2014 | 100% |
| Marnie Lynn Ventling-Herrmann |
Corporate Director |
Jan 1, 2022 | |
| Tony Lee Morrison |
Corporate Officer |
Feb 1, 1991 | |
| W-2 Managing Employee |
Feb 1, 1991 | ||
| James Edward Cain |
Corporate Director | Nov 19, 2015 | |
| Karin Louise Dulski |
W-2 Managing Employee |
Nov 19, 2012 | |
| Sanford |
5% Or Greater Indirect Ownership Interest | Mar 1, 2011 | 100% |
| Mark Roger Paulson |
Corporate Director | Jul 1, 2010 | |
| Brent Gerard Teiken |
Corporate Director | Mar 1, 2011 | |
| Jolyn Joy Munson |
W-2 Managing Employee |
Feb 25, 2013 | |
| Andrew Stewart North |
Corporate Director | Jan 1, 2017 | |
| Stephanie Marie Swenson |
W-2 Managing Employee |
Nov 1, 2019 | |
| Michelle Marie Micka |
Corporate Officer |
Jan 6, 2019 | |
| W-2 Managing Employee |
Jan 6, 2019 | ||
| William Joseph Gassen |
Corporate Officer |
Nov 24, 2020 | |
| Corporate Director |
Nov 24, 2020 | ||
| W-2 Managing Employee |
Nov 24, 2020 | ||
| Wesley Owen Engbrecht |
Corporate Director |
Jan 1, 2021 | |
| Donald Darwin Jacobs |
Corporate Director | Dec 4, 2014 | |
| Michelle Ann Bruhn |
Corporate Officer |
Dec 2, 2021 | |
| W-2 Managing Employee |
Dec 2, 2021 | ||
| Neil Leslie Gulsvig |
Corporate Director | Mar 28, 2019 | |
| Lauris Nelson Molbert |
Corporate Director |
Jan 6, 2021 | |
| Robin Lisa Smith |
Corporate Director |
Jan 1, 2021 | |
| Sanford North |
5% Or Greater Direct Ownership Interest | Jul 1, 2010 | 100% |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20110331000495 | ND | Part B Supplier - Clinic/Group Practice | 8426967803 |
Receives reassigned benefits from 1,593 practitioners 5 other NPIs on this enrollment This NPI is an additional NPI on the enrollment |
| O20221227001238 | ND | Part a Provider - Rural Health Clinic | 8426967803 | Practice locations: Forman, ND |
National Provider Directory
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Rural Health Clinic/Center | 261QR1300X | Yes |
Addresses
Primary practice location
336 Main Street
Forman, ND 58032-0184
Mailing address
PO Box 2168
Fargo, ND 58107-2168
Phone (701) 234-2119
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1331001 | Other | ND | BLUE SHIELD |
| 12857 | Medicaid | ND | |
| 5128 | Medicaid | ND | |
| CF8850 | Other | ND | RAILROAD MEDICARE |
Other names
- Sanford Health Forman Clinic
Electronic endpoints
| Type | Endpoint | Use | Affiliation |
|---|---|---|---|
| CONNECT URL | https://cobiusconnect.cobius.com:8291/Gateway/DocumentSubmission/2_0/NhinService/XDRRequest_Service | Other | Cobius Healthcare Solutions |
Other providers in Forman, ND
- Four Seasons Healthcare Center Inc
- Michele H Gilbertson
- Kari Gilje
- Rosanne Clare Lohman
- Kelsy Martinson
- Sargent County Ambulance Forman Squad
- Sargent County Social Services
- Nathan Wilbur Schlecht
- Southeast Therapy Services Inc
All providers in Forman, ND · Rural Health Clinic/Center in North Dakota
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Nov 29, 2022. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- CMS facility enrollments, All Owners and change-of-ownership files: CCNs, owners and managing parties.
- Provider of Services files (CMS): certification status, beds and related CCNs.
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.