Sanford Health of Northern Minnesota
Organization Active NPI Rural Health Clinic/Center · Bagley, MN
NPI 1972875490 · NPPES record last updated Jan 23, 2025
Key facts
- NPI
- 1972875490
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Rural Health Clinic/Center 261QR1300X
- Legal business name
- SANFORD HEALTH OF NORTHERN MINNESOTA
- Practice address
- 1656 Central St W
Bagley, MN 56621-4357 - Phone
- (218) 694-2384
- Fax
- (218) 694-6687
- NPI assigned
- Jan 30, 2012
- Organization subpart
- No
Authorized official
- Name
- Tony Lee Morrison
- Title
- Vice President, Revenue Cycle
- Phone
- (605) 328-8380
Owners & managing parties with NPI records 2
Other NPIs on the same Medicare enrollment 11
Other NPIs with the same Medicare PAC ID 20
Related certifications (CCN) 1
Facilities with the same owner 31
Practitioners 365
-
Stacy Marie Smith, MPAS, PA-C
-
Tyler Junttila, MD
-
Jayci Jo McCrory, OD
-
Angela Aakhus, M.D.
-
Randall Jay Ambroz, M.D.
-
Jonas Attilus, MD
-
Kimberly Jean Sletta Avenson, MSW, LICSW
-
Mohammed Azeemuddin, APRN, CNP
-
Prabhdeep Kaur Bajwa, M.D.
-
Emmalee Elaine Bardwell, O.D.
-
Ronald W. Bardwell, C.R.N.A.
-
Elizabeth Bernice Berg, M.D.
-
Sherry S Billups, DO
-
Katlyn Bowman, PMHNP-BC
-
Lauren Bradel-Warlick, PHD, LP
Laboratory certificates & supplier records
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 24D0895892 | Sanford Bagley Clinic | Certificate of waiver | May 20, 2028 |
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled (2 enrollments) in MN
Rural health clinic certification: CCN 243418
- Legal name
- SANFORD HEALTH OF NORTHERN MINNESOTA
- Doing business as
- SANFORD BAGLEY CLINIC
- Certification status
- Active
- Provider type (POS)
- Rural health clinic
- Participating since
- Apr 1, 2002
- Last certification
- Jul 15, 2015
- Ownership / control type
- 2B
- Most recent change of ownership
- Feb 1, 2012 (1 total)
- Organization structure
- Corporation · Non-profit
- Incorporated
- Nov 11, 1975 in MN
- Enrollment address
- 1656 Central St W
Bagley, MN 56621-4357 - Related CCNs
- 241328
All disclosed owners & managing parties 24
| Name | Role | Since | Share |
|---|---|---|---|
| Mark Allen Lundeen |
Corporate Director |
Dec 4, 2014 | |
| Jason Joseph Caron |
W-2 Managing Employee |
Jan 1, 2026 | |
| Marnie Lynn Ventling-Herrmann |
Corporate Director |
Jan 1, 2022 | |
| Tony Lee Morrison |
W-2 Managing Employee |
Jan 19, 2020 | |
| Daniel George Hoody |
W-2 Managing Employee |
Oct 9, 2023 | |
| Brent Gerard Teiken |
Corporate Director |
Jul 3, 2012 | |
| Jolyn Joy Munson |
W-2 Managing Employee |
Apr 17, 2025 | |
| Dana James Dykhouse |
Corporate Director |
Jan 1, 2024 | |
| Andrew Stewart North |
Corporate Director |
Jan 1, 2017 | |
| Renee Marie Axtman |
W-2 Managing Employee |
Jan 1, 2026 | |
| Stephanie Marie Herseth Sandlin |
Corporate Director |
Jan 1, 2024 | |
| William Joseph Gassen |
Corporate Director |
Nov 23, 2020 | |
| George Joseph Brown |
Corporate Director |
Jan 1, 2025 | |
| Wesley Owen Engbrecht |
Corporate Director |
Jan 1, 2021 | |
| Maureen Patricia McCausland |
Corporate Director |
Jan 1, 2025 | |
| Sanford |
5% Or Greater Indirect Ownership Interest | Feb 1, 2012 | 100% |
| Lisa Sue Miller |
W-2 Managing Employee |
Sep 9, 2019 | |
| Thomas Richard Wenzel |
Corporate Director |
Jan 1, 2025 | |
| David Jonathan Shulkin |
Corporate Director |
Jan 1, 2024 | |
| Neil Leslie Gulsvig |
Corporate Director |
Mar 28, 2019 | |
| Kevin Victor Schieffer |
Corporate Director |
Jan 1, 2025 | |
| Lauris Nelson Molbert |
Corporate Director |
Jan 1, 2021 | |
| Nicholas Wayne Olson |
W-2 Managing Employee |
Apr 8, 2024 | |
| Sanford North |
5% Or Greater Direct Ownership Interest | Mar 1, 2011 | 100% |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20041025000442 | MN | Part B Supplier - Clinic/Group Practice | 5597725168 |
Receives reassigned benefits from 644 practitioners 12 other NPIs on this enrollment This NPI is an additional NPI on the enrollment Practice locations: Bemidji, MN; International Falls, MN; Kelliher, MN; Minneapolis, MN; Dover, MN; Osage, MN; Park Rapids, MN; Perham, MN… |
| O20170921000215 | MN | Part a Provider - Rural Health Clinic | 5597725168 | Practice locations: Bagley, MN |
National Provider Directory
Locations
3220 Hannah Ave NW
Ste 1
Bemidji, MN 56601
Phone (218) 209-3600
506 Beltrami Ave NW
Bemidji, MN 56601
Phone (218) 751-2020
3717 Pine Ridge Ave NW
Bemidji, MN 56601
Phone (218) 333-4527
22 Elm St
Clearbrook, MN 56634
Phone (218) 694-3124
1680 Diagonal Rd
Worthington, MN 56187
Phone (507) 372-3800
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Rural Health Clinic/Center | 261QR1300X | Yes |
Addresses
Primary practice location
1656 Central St W
Bagley, MN 56621-4357
Mailing address
PO Box 5074
Sioux Falls, SD 57117-5074
Phone (605) 328-6585
Other names
- Sanford Bagley Clinic
Electronic endpoints
| Type | Endpoint | Use | Affiliation |
|---|---|---|---|
| CONNECT URL | https://cobiusconnect.cobius.com:8291/Gateway/DocumentSubmission/2_0/NhinService/XDRRequest_Service | Other |
Other providers in Bagley, MN
- Elizabeth Riek
- Jenise Nicole Ropp
- Jenna Kae Sagedahl
- Sanford Health of Northern Minnesota
- Sanford Health of Northern Minnesota
- Amanda Jo Schmit
- Carrie Schwegman-Norum
- Stacy Marie Sorenson
- Andre Spence
- Brittany Ann Stang
All providers in Bagley, MN · Rural Health Clinic/Center in Minnesota
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jan 23, 2025. 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.