NPIMap

Organization Active NPI

Sanford Medical Center Fargo

Doing business as Sanford Health Forman Clinic

  • Rural Health Clinic/Center
  • Forman, ND
National Provider Identifier
1073520003
Registry record updated Nov 29, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
SANFORD MEDICAL CENTER FARGO
Doing business as
Sanford Health Forman Clinic
Practice address
336 Main Street
Forman, ND 58032-0184
Phone
(701) 724-3221
Fax
(701) 724-3222
NPI assigned
Aug 2, 2006
Last updated
Nov 29, 2022By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Nov 29, 2022

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Tony Lee Morrison
Title
Vice President, Revenue Cycle
Phone
(605) 328-8380

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Rural Health Clinic/Center 261QR1300X Primary

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 4

IdentifierTypeStateIssuer
5128MedicaidND
12857MedicaidND
CF8850OtherNDRAILROAD MEDICARE
1331001OtherNDBLUE SHIELD

Other names 1

  • Sanford Health Forman Clinic Doing business as

Electronic endpoints 1

TypeEndpointUseAffiliation
CONNECT URL https://cobiusconnect.cobius.com:8291/Gateway/DocumentSubmission/2_0/NhinService/XDRRequest_Service Other Cobius Healthcare Solutions

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in ND2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
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

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1073520003. Details of each certification follow.

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
CorporationProprietary
Enrollment address
336 Main Street
Sanford Healthforman Clinic
Forman, ND 58032-0184

Other NPIs on the same Medicare enrollment 5

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
35D0408194Sanford Health Forman Clinic336 Main St W, Forman, ND 58032Certificate of waiverFeb 29, 2028

National Provider Directory

National Provider Directory

Locations

618 14th Ave NE
Devils Lake, ND 58301
Phone (701) 544-7000

Ownership & related parties

All disclosed owners & managing parties 21

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Mark Allen Lundeen Individual Corporate Director Dec 4, 2014
Maria Caroline Bell Individual Corporate DirectorBoard Member Aug 1, 2014 100%
Marnie Lynn Ventling-Herrmann Individual Corporate DirectorDirector Jan 1, 2022
Tony Lee Morrison Individual Corporate OfficerVP, Revenue Cycle Feb 1, 1991
W-2 Managing EmployeeVP, Revenue Cycle Feb 1, 1991
James Edward Cain Individual Corporate Director Nov 19, 2015
Karin Louise Dulski Individual W-2 Managing EmployeeDirector, Revenue Management Nov 19, 2012
Sanford Organization, Fargo, ND Non-profit 5% Or Greater Indirect Ownership Interest Mar 1, 2011 100%
Mark Roger Paulson Individual Corporate Director Jul 1, 2010
Brent Gerard Teiken Individual Corporate Director Mar 1, 2011
Jolyn Joy Munson Individual W-2 Managing EmployeeSr. Director of PFS Feb 25, 2013
Andrew Stewart North Individual Corporate Director Jan 1, 2017
Stephanie Marie Swenson Individual W-2 Managing EmployeeDirector, Insurance Nov 1, 2019
Michelle Marie Micka Individual Corporate OfficerSenior VP, Finance Jan 6, 2019
W-2 Managing EmployeeSenior VP, Finance Jan 6, 2019
William Joseph Gassen Individual Corporate OfficerPresident and Ceo Nov 24, 2020
Corporate DirectorPresident and Ceo Nov 24, 2020
W-2 Managing EmployeePresident and Ceo Nov 24, 2020
Wesley Owen Engbrecht Individual Corporate DirectorBoard of Trustes Jan 1, 2021
Donald Darwin Jacobs Individual Corporate Director Dec 4, 2014
Michelle Ann Bruhn Individual Corporate OfficerCfo, VP, Treasurer Dec 2, 2021
W-2 Managing EmployeeCfo, VP, Treasurer Dec 2, 2021
Neil Leslie Gulsvig Individual Corporate Director Mar 28, 2019
Lauris Nelson Molbert Individual Corporate DirectorBoard of Trustees Jan 6, 2021
Robin Lisa Smith Individual Corporate DirectorBoard of Trustees Jan 1, 2021
Sanford North Organization, Bismarck, ND Non-profit 5% Or Greater Direct Ownership Interest Jul 1, 2010 100%

Owners & managing parties with NPI records 1

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

Facilities with the same owner 42

Facilities that share an organizational owner with 5% or greater ownership or operational control.

View all 42

Practitioners & affiliated clinicians

Practitioners 99

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 99

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1154476800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1669680000000",
    "number": "1073520003",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 2168",
            "city": "FARGO",
            "state": "ND",
            "postal_code": "581072168",
            "telephone_number": "701-234-2119"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "336 MAIN STREET",
            "city": "FORMAN",
            "state": "ND",
            "postal_code": "580320184",
            "telephone_number": "701-724-3221",
            "fax_number": "701-724-3222"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SANFORD MEDICAL CENTER FARGO",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-08-02",
        "last_updated": "2022-11-29",
        "certification_date": "2022-11-29",
        "status": "A",
        "authorized_official_last_name": "MORRISON",
        "authorized_official_first_name": "TONY",
        "authorized_official_middle_name": "LEE",
        "authorized_official_title_or_position": "VICE PRESIDENT, REVENUE CYCLE",
        "authorized_official_telephone_number": "605-328-8380"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "5128",
            "state": "ND"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "12857",
            "state": "ND"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "RAILROAD MEDICARE",
            "identifier": "CF8850",
            "state": "ND"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE SHIELD",
            "identifier": "1331001",
            "state": "ND"
        }
    ],
    "endpoints": [
        {
            "endpointType": "CONNECT",
            "endpointTypeDescription": "CONNECT URL",
            "endpoint": "https://cobiusconnect.cobius.com:8291/Gateway/DocumentSubmission/2_0/NhinService/XDRRequest_Service",
            "affiliation": "Y",
            "endpointDescription": "2.16.840.1.113883.3.1068.1",
            "affiliationName": "Cobius Healthcare Solutions",
            "use": "OTHER",
            "useDescription": "Other",
            "useOtherDescription": "CMS esMD eMDR",
            "address_1": "2720 Dundee Rd # 302",
            "city": "Northbrook",
            "state": "IL",
            "country_code": "US",
            "postal_code": "600622609",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": [
        {
            "organization_name": "Sanford Health Forman Clinic",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Sanford Health Forman Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Forman, ND

Sources for this page

Verify at the official NPI Registry.