NPIMap

Organization Active NPI

Sanford Health of Northern Minnesota

  • Family Medicine Physician
  • Kelliher, MN
National Provider Identifier
1770849697
Registry record updated Aug 4, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
Legal business name
SANFORD HEALTH OF NORTHERN MINNESOTA
Practice address
243 Clark Ave N
Kelliher, MN 56650-3015
Phone
(218) 647-8832
Fax
(218) 647-8127
NPI assigned
Apr 4, 2012
Reactivated
Jun 24, 2022
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 4, 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
Family Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207Q00000X Primary

Addresses

Primary practice location

243 Clark Ave N
Kelliher, MN 56650-3015

Mailing address

345 4TH St NW
Kelliher, MN 56650
Phone (218) 647-8832

Other names 1

  • Sanford Health Kelliher Clinic Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MN

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20041025000442 MN Part B Supplier - Clinic/Group Practice 5597725168 Receives reassigned benefits from 644 practitioners
12 other NPIs on this enrollment
Practice locations: Bemidji, MN; International Falls, MN; Kelliher, MN; Minneapolis, MN; Dover, MN; Osage, MN; Park Rapids, MN; Perham, MN…

Other NPIs with the same Medicare PAC ID 20

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

View all 20

Other NPIs on the same Medicare enrollment 11

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

National Provider Directory

National Provider Directory

Locations

345 4th St NW
Kelliher, MN 56650
Phone (218) 647-3206

Practitioners & affiliated clinicians

Practitioners 694

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

View all 694

NPI Registry JSON

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

{
    "created_epoch": "1333497600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1659571200000",
    "number": "1770849697",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "345 4TH ST NW",
            "city": "KELLIHER",
            "state": "MN",
            "postal_code": "56650",
            "telephone_number": "218-647-8832",
            "fax_number": "218-647-8127"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "243 CLARK AVE N",
            "city": "KELLIHER",
            "state": "MN",
            "postal_code": "566503015",
            "telephone_number": "218-647-8832",
            "fax_number": "218-647-8127"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SANFORD HEALTH OF NORTHERN MINNESOTA",
        "organizational_subpart": "NO",
        "enumeration_date": "2012-04-04",
        "last_updated": "2022-08-04",
        "certification_date": "2022-07-28",
        "deactivation_date": "2022-05-18",
        "reactivation_date": "2022-06-24",
        "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": "207Q00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Sanford Health Kelliher Clinic",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Sanford Health Kelliher Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Kelliher, MN

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 4, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.