NPIMap

Organization Active NPI

Sanford Medical Center Fargo

Doing business as Sanford Health Mahnomen Clinic

  • Rural Health Clinic/Center
  • Mahnomen, MN
National Provider Identifier
1831131234
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 Mahnomen Clinic
Practice address
410 4TH St NW
Mahnomen, MN 56557-4208
Phone
(218) 935-2514
Fax
(218) 935-2720
NPI assigned
Jun 11, 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 4

Specialty (taxonomy)CodeLicenseStatePrimary
Rural Health Clinic/Center 261QR1300X Primary
Family Medicine Physician 207Q00000X
Internal Medicine Physician 207R00000X
Obstetrics & Gynecology Physician 207V00000X

Addresses

Primary practice location

410 4TH St NW
Mahnomen, MN 56557-4208

Mailing address

PO Box 2168
Fargo, ND 58107-2168
Phone (701) 234-2119

Other identifiers 1

IdentifierTypeStateIssuer
954222100MedicaidMN

Other names 1

  • Sanford Health Mahnomen 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 MN2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20110701000031 MN Part B Supplier - Clinic/Group Practice 8426967803 Receives reassigned benefits from 411 practitioners
4 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Rochester, MN; Morris, MN; Perham, MN; Pelican Rapids, MN; Parkers Prairie, MN; Ortonville, MN; North Oaks, MN; New York Mills, MN…
O20230207001753 MN Part A Provider - Rural Health Clinic 8426967803 Practice locations: Mahnomen, MN

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1831131234. Details of each certification follow.

Rural health clinic certification: CCN 243850

Legal name
SANFORD MEDICAL CENTER FARGO
Doing business as
SANFORD HEALTH MAHNOMEN CLINIC
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Apr 1, 1999
Last certification
May 8, 2014
Ownership / control type
2B
Organization structure
CorporationNon-profit
Enrollment address
410 West 4TH Street
Mahnomen, MN 56557-0997

Other NPIs on the same Medicare enrollment 4

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
24D0726258Sanford Health Mahnomen Clinic410 West 4TH Street, Mahnomen, MN 56557Certificate of waiverAug 31, 2026

National Provider Directory

National Provider Directory
Tax ID family
St Lukes Hospital71 organizations share this tax ID, including this one

Organizations with this tax ID in the same state 16

This tax ID family is large, so up to 24 of its organizations in the same state are linked here.

View all 16

Ownership & related parties

All disclosed owners & managing parties 24

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 DirectorTrustee Dec 4, 2014
Marnie Lynn Ventling-Herrmann Individual Corporate OfficerVice Chair Person Jan 1, 2024
Corporate DirectorDirector Jan 1, 2022
Tony Lee Morrison Individual W-2 Managing EmployeeVP, Chief Revenue Cycle Officer Jan 19, 2020
Sanford Organization, Bismarck, ND Non-profit 5% Or Greater Indirect Ownership Interest Jul 17, 2010 100%
Brent Gerard Teiken Individual Corporate DirectorTrustee Jul 3, 2012
Susan Drake Jarvis Individual W-2 Managing Employee Jan 1, 2023
Kristin Kaye Herrmann Individual W-2 Managing EmployeeCfo, Fargo Apr 24, 2022
Jolyn Joy Munson Individual W-2 Managing EmployeeVP, Revenue Cycle Operations Apr 17, 2025
Dana James Dykhouse Individual Corporate Director Jan 1, 2024
Andrew Stewart North Individual Corporate OfficerSecretary Jan 1, 2020
Corporate DirectorTrustee Jan 1, 2017
Stephanie Marie Herseth Sandlin Individual Corporate DirectorTrustee Jan 1, 2024
William Joseph Gassen Individual Corporate OfficerCeo Nov 24, 2020
Corporate DirectorTrustee Nov 24, 2020
Douglas Marlin Griffin Individual W-2 Managing Employee Sep 25, 2022
George Joseph Brown Individual Corporate OfficerTreasurer Jan 1, 2025
Corporate DirectorTrustee Jan 1, 2025
Wesley Owen Engbrecht Individual Corporate DirectorTrustee Jan 1, 2021
Maureen Patricia McCausland Individual Corporate DirectorTrustee Jan 1, 2025
Tiffany L Lawrence Individual Corporate OfficerPresident Mar 3, 2022
W-2 Managing EmployeePresident Mar 3, 2022
Thomas Richard Wenzel Individual Corporate DirectorTrustee Jan 1, 2025
David Jonathan Shulkin Individual Corporate DirectorTrustee Jan 1, 2025
Neil Leslie Gulsvig Individual Corporate DirectorTrustee Mar 28, 2019
Kevin Victor Schieffer Individual Corporate DirectorTrustee Jan 1, 2025
Lauris Nelson Molbert Individual Corporate OfficerChair Person Jan 1, 2024
Corporate DirectorTrustee Jan 1, 2021
Nicholas Wayne Olson Individual W-2 Managing EmployeeCfo Apr 8, 2024
Sanford North Organization, Fargo, ND Non-profit 5% Or Greater Direct Ownership Interest Jul 1, 1999 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 22

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 22

NPI Registry JSON

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

{
    "created_epoch": "1149984000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1669680000000",
    "number": "1831131234",
    "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": "410 4TH ST NW",
            "city": "MAHNOMEN",
            "state": "MN",
            "postal_code": "565574208",
            "telephone_number": "218-935-2514",
            "fax_number": "218-935-2720"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SANFORD MEDICAL CENTER FARGO",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-06-11",
        "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
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207R00000X",
            "taxonomy_group": "",
            "desc": "Internal Medicine",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207V00000X",
            "taxonomy_group": "",
            "desc": "Obstetrics & Gynecology",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "954222100",
            "state": "MN"
        }
    ],
    "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 Mahnomen Clinic",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Sanford Health Mahnomen Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Mahnomen, MN

Sources for this page

Verify at the official NPI Registry.