NPIMap

Organization Active NPI

Sanford Health of Northern Minnesota

Doing business as Sanford Bagley Clinic

  • Rural Health Clinic/Center
  • Bagley, MN
National Provider Identifier
1972875490
Registry record updated Jan 23, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
SANFORD HEALTH OF NORTHERN MINNESOTA
Doing business as
Sanford Bagley Clinic
Practice address
1656 Central St W
Bagley, MN 56621-4357
Phone
(218) 694-2384
Fax
(218) 694-6687
NPI assigned
Jan 30, 2012
Last updated
Jan 23, 2025By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jan 23, 2025

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

1656 Central St W
Bagley, MN 56621-4357

Mailing address

PO Box 5074
Sioux Falls, SD 57117-5074
Phone (605) 328-6585

Other names 1

  • Sanford Bagley Clinic Doing business as

Electronic endpoints 1

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

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MN2 enrollments

Enrollment records 2

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
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

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1972875490. Details of each certification follow.

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
CorporationNon-profit
Incorporated
Nov 11, 1975 in MN
Enrollment address
1656 Central St W
Bagley, MN 56621-4357
Related CCNs
241328

Facilities connected through Provider of Services related, parent or unit certification numbers.

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.

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
24D0895892Sanford Bagley Clinic1656 Central Street West, Bagley, MN 56621Certificate of waiverMay 20, 2028

National Provider Directory

National Provider Directory

Locations

3220 Hannah Ave NW
Ste 1
Bemidji, MN 56601
Phone (218) 209-3600

3220 Hannah Ave NW
Ste 2
Bemidji, MN 56601
Phone (218) 209-3600

1400 Highway 71
Ste E
International Falls, MN 56649
Phone (218) 598-5665

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
Jason Joseph Caron Individual W-2 Managing EmployeePresident Jan 1, 2026
Marnie Lynn Ventling-Herrmann Individual Corporate DirectorTrustee Jan 1, 2022
Tony Lee Morrison Individual W-2 Managing EmployeeVP Chief Revenue Cycle Officer Jan 19, 2020
Daniel George Hoody Individual W-2 Managing EmployeeChief Physician and Medical Officer Oct 9, 2023
Brent Gerard Teiken Individual Corporate DirectorTrustee Jul 3, 2012
Jolyn Joy Munson Individual W-2 Managing EmployeeVP Revenue Cycle Operations Apr 17, 2025
Dana James Dykhouse Individual Corporate DirectorTrustee Jan 1, 2024
Andrew Stewart North Individual Corporate DirectorTrustee Jan 1, 2017
Renee Marie Axtman Individual W-2 Managing EmployeeChief Operations Officer, Bemidji Jan 1, 2026
Stephanie Marie Herseth Sandlin Individual Corporate DirectorTrustee Jan 1, 2024
William Joseph Gassen Individual Corporate DirectorTrustee/Ceo Nov 23, 2020
George Joseph Brown Individual Corporate DirectorTrustee Jan 1, 2025
Wesley Owen Engbrecht Individual Corporate DirectorTrustee Jan 1, 2021
Maureen Patricia McCausland Individual Corporate DirectorTrustee Jan 1, 2025
Sanford Organization, Fargo, ND Non-profit 5% Or Greater Indirect Ownership Interest Feb 1, 2012 100%
Lisa Sue Miller Individual W-2 Managing EmployeeChief Financial Officer, Bemidji Sep 9, 2019
Thomas Richard Wenzel Individual Corporate DirectorTrustee Jan 1, 2025
David Jonathan Shulkin Individual Corporate DirectorTrustee Jan 1, 2024
Neil Leslie Gulsvig Individual Corporate DirectorTrustee Mar 28, 2019
Kevin Victor Schieffer Individual Corporate DirectorTrustee Jan 1, 2025
Lauris Nelson Molbert Individual Corporate DirectorTrustee Jan 1, 2021
Nicholas Wayne Olson Individual W-2 Managing EmployeeChief Financial Officer Apr 8, 2024
Sanford North Organization, Bismarck, ND Corporation, Non-profit 5% Or Greater Direct Ownership Interest Mar 1, 2011 100%

Owners & managing parties with NPI records 2

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

Facilities with the same owner 31

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

View all 31

Practitioners & affiliated clinicians

Practitioners 20

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 20

NPI Registry JSON

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

{
    "created_epoch": "1327881600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1737590400000",
    "number": "1972875490",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 5074",
            "city": "SIOUX FALLS",
            "state": "SD",
            "postal_code": "571175074",
            "telephone_number": "605-328-6585"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1656 CENTRAL ST W",
            "city": "BAGLEY",
            "state": "MN",
            "postal_code": "566214357",
            "telephone_number": "218-694-2384",
            "fax_number": "218-694-6687"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SANFORD HEALTH OF NORTHERN MINNESOTA",
        "organizational_subpart": "NO",
        "enumeration_date": "2012-01-30",
        "last_updated": "2025-01-23",
        "certification_date": "2025-01-23",
        "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": [],
    "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",
            "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 Bagley Clinic",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Sanford Bagley Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Bagley, MN

Sources for this page

Verify at the official NPI Registry.