Covered Entity Details

DSH240100U Sanford Bemidji Medical Center (Active) - information as of 4/26/2025 11:38:52 PM

Main Details

Name

Sanford Bemidji Medical Center

Subdivision Name

SANFORD BEMIDJI MAIN CLINIC / Internal Medicine

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH240100U

Medicare Provider Number

240100

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

1/15/2015

Participating Start Date

4/1/2015

Participating Approval Date

3/11/2015

Last Recertification Date

8/22/2024

Contacts

Authorizing Official

Sanford Health of Northern Minnesota
Lisa Sue Miller, Chief Financial Officer
(218) 333-5523

Primary Contact

Sanford Health of Northern Minnesota
Matthew Aaron Webb, Director of Pharmacy
(218) 333-6339

Addresses

Street Address

1233 34TH ST NW
BEMIDJI, MN 56601-5112

Billing Address

Sanford Bemidji Medical Center
1300 ANNE STREET NW
BEMIDJI, MN 56601

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
History

Comments

Comment	Last Updated On
No records to display.

Medicaid Billing

At this site, will the covered entity bill Medicaid fee-for-service for drugs purchased at 340B prices?
Yes

State	Medicaid Number	NPI Number
MN	314545001,314545000	1801870191,1982166765,1679677124,1083933824

Shipping Addresses

Shipping Address 1

Sanford Bemidji Medical Center
1300 ANNE STREET NW
BEMIDJI, MN 56601

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Carve-In Effective Date	Termination Date	Last Updated On
No records to display.

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
DSH240100A	Child	DSH	Sanford Bemidji Medical Center	Sanford Bemidji 1611 Anne Street Clinic	1611 Anne Street NW	Bemidji	MN	Terminated
DSH240100AA	Child	DSH	Sanford Bemidji Medical Center	SANFORD BEMIDJI MAIN CLINIC / Radiation Oncology	1233 34TH ST NW	BEMIDJI	MN	Active
DSH240100AB	Child	DSH	Sanford Bemidji Medical Center	SANFORD BEMIDJI MAIN CLINIC / Rheumatology	1233 34TH ST NW	BEMIDJI	MN	Terminated
DSH240100AC	Child	DSH	Sanford Bemidji Medical Center	SANFORD BEMIDJI MAIN CLINIC / Ob/Gyn	1233 34TH ST NW	BEMIDJI	MN	Active
DSH240100AD	Child	DSH	Sanford Bemidji Medical Center	SANFORD BEMIDJI MAIN CLINIC / Urology	1233 34TH ST NW	BEMIDJI	MN	Active
DSH240100AE	Child	DSH	Sanford Bemidji Medical Center	SANFORD BEMIDJI MAIN CLINIC / General Surgery	1233 34TH ST NW	BEMIDJI	MN	Active
DSH240100AF	Child	DSH	Sanford Bemidji Medical Center	SANFORD BEMIDJI / ENT	1705 Anne Street NW	BEMIDJI	MN	Active
DSH240100AG	Child	DSH	Sanford Bemidji Medical Center	Hospice	3201 Pine Ridge Avenue NW	Bemidji	MN	Terminated
DSH240100AH	Child	DSH	Sanford Bemidji Medical Center	Sanford Clinic 1611 Anne / Allergy Clinic	1611 Anne Street NW	Bemidji	MN	Terminated
DSH240100AJ	Child	DSH	Sanford Bemidji Medical Center	Infusion Center	1233 34th Street NW	Bemidji	MN	Active
DSH240100AK	Child	DSH	Sanford Bemidji Medical Center	Sanford Bemidji Main Clinic / Breast Clinic	1233 34th Street NW	Bemidji	MN	Active
DSH240100AL	Child	DSH	Sanford Bemidji Medical Center	Sanford Bemidji Main Clinic / Surgery Center	1233 34th Street NW	Bemidji	MN	Terminated
DSH240100AM	Child	DSH	Sanford Bemidji Medical Center	1611 Clinic Radiology	1611 Anne Street NW	Bemidji	MN	Active
DSH240100AN	Child	DSH	Sanford Bemidji Medical Center	SANFORD BEMIDJI MAIN CLINIC / Rheumatology Clinic	1233 34TH ST NW	Bemidji	MN	Active
DSH240100AP	Child	DSH	Sanford Bemidji Medical Center	Anti-coagulation Clinic	1611 Anne Street NW	Bemidji	MN	Active
DSH240100AQ	Child	DSH	Sanford Bemidji Medical Center	Gastroenterology Clinic	1233 34th Street NW	Bemidji	MN	Active
DSH240100AR	Child	DSH	Sanford Bemidji Medical Center	Pulmonology Clinic	1233 34th Street NW	Bemidji	MN	Active
DSH240100AS	Child	DSH	Sanford Bemidji Medical Center	Main Clinic Radiology	1233 34th Street NW	Bemidji	MN	Terminated
DSH240100AT	Child	DSH	Sanford Bemidji Medical Center	Main Clinic Diabetic Education	1233 34th St NW	Bemidji	MN	Terminated
DSH240100AU	Child	DSH	Sanford Bemidji Medical Center	Anne Street Clinic - Peds Psych	1611 Anne Street NW	Bemidji	MN	Terminated
DSH240100AV	Child	DSH	Sanford Bemidji Medical Center	Anne Street Clinic - Child Psychology	1611 Anne Street NW	Bemidji	MN	Terminated
DSH240100AW	Child	DSH	Sanford Bemidji Medical Center	Anne Street Clinic - Peds Neurology	1611 Anne Street NW	Bemidji	MN	Terminated
DSH240100AX	Child	DSH	Sanford Bemidji Medical Center	Anne Street Clinic - Outreach 1611	1611 Anne Street NW	Bemidji	MN	Active
DSH240100AY	Child	DSH	Sanford Bemidji Medical Center	Sanford Bemidji 1611 Anne Street Clinic/Endocrinology	1611 Anne Street NW	Bemidji	MN	Terminated
DSH240100AZ	Child	DSH	Sanford Bemidji Medical Center	Same Day Surgery - Intra Op Care	1233 34th Street NW	Bemidji	MN	Active
DSH240100B	Child	DSH	Sanford Bemidji Medical Center	BJI OPHTH DWNTN	506 Beltrami Avenue NW	Bemidji	MN	Active
DSH240100BA	Child	DSH	Sanford Bemidji Medical Center	Same Day Surgery - Same Day Unit	1233 34th Street NW	Bemidji	MN	Terminated
DSH240100BB	Child	DSH	Sanford Bemidji Medical Center	Same Day Surgery - Recovery Care	1233 34th Street NW	Bemidji	MN	Active
DSH240100BC	Child	DSH	Sanford Bemidji Medical Center	Same Day Surgery - Preop Holding	1233 34th Street NW	Bemidji	MN	Active
DSH240100BD	Child	DSH	Sanford Bemidji Medical Center	Same Day Surgery - PACU	1233 34th Street NW	Bemidji	MN	Active
DSH240100BE	Child	DSH	Sanford Bemidji Medical Center	Sanford Bemidji Palliative Care - Sanford Bemidji Palliative Care	1233 34th Street NW	Bemidji	MN	Active
DSH240100BF	Child	DSH	Sanford Bemidji Medical Center	Sanford Bemidji Radiology Main - Sanford Bemidji Radiology Main	1233 34th Street NW	Bemidji	MN	Active
DSH240100BG	Child	DSH	Sanford Bemidji Medical Center	Sanford Bemidji Rad Onc Therapy - Sanford Bemidji Rad Onc Therapy	1233 34th Street NW	Bemidji	MN	Terminated
DSH240100BH	Child	DSH	Sanford Bemidji Medical Center	Sanford Bemidji Diabetes Center - Sanford Bemidji Diabetes Center	1233 34th St NW	Bemidji	MN	Active
DSH240100BJ	Child	DSH	Sanford Bemidji Medical Center	Recovery Medicine Clinic	1705 Anne Street NW	Bemidji	MN	Active
DSH240100BK	Child	DSH	Sanford Bemidji Medical Center	Sanford Main Clinic/Pain Center - Pain Clinic	1233 34th Street NW	Bemidji	MN	Active
DSH240100BL	Child	DSH	Sanford Bemidji Medical Center	Sanford Bemidji Neuro Med Oncology - Neuro Med	1233 34th Street NW	Bemidji	MN	Terminated
DSH240100BM	Child	DSH	Sanford Bemidji Medical Center	Sanford Main Clinic / Outreach - Outreach	1233 34TH STREET NW	Bemidji	MN	Active
DSH240100BN	Child	DSH	Sanford Bemidji Medical Center	SANFORD HEALTH OF NORTHERN MINNESOT - OB/GYN	614 MICHIGAN AVE W	WALKER	MN	Active
DSH240100BP	Child	DSH	Sanford Bemidji Medical Center	SANFORD HEALTH OF NORTHERN MINNESOT - Radiology	614 MICHIGAN AVE W	WALKER	MN	Terminated
DSH240100BQ	Child	DSH	Sanford Bemidji Medical Center	SANFORD HEALTH OF NORTHERN MINNESOT - Family Medicine	614 MICHIGAN AVE W	WALKER	MN	Active
DSH240100BR	Child	DSH	Sanford Bemidji Medical Center	SANFORD BEMIDJI 1705 ANNE ST CLINIC - Audiology	1705 ANNE ST NW	BEMIDJI	MN	Active
DSH240100BS	Child	DSH	Sanford Bemidji Medical Center	SANFORD HEALTH OF NORTHERN MINNESOT - Podiatry	614 MICHIGAN AVE W	WALKER	MN	Active
DSH240100BT	Child	DSH	Sanford Bemidji Medical Center	SANFORD BEMIDJI 1705 ANNE ST CLINIC - Psychiatry	1705 ANNE ST NW	BEMIDJI	MN	Active
DSH240100BU	Child	DSH	Sanford Bemidji Medical Center	SANFORD BEMIDJI MAIN CLINIC - Oncology Lab	1233 34TH ST NW	BEMIDJI	MN	Terminated
DSH240100BV	Child	DSH	Sanford Bemidji Medical Center	SANFORD HEALTH OF NORTHERN MINNESOT - Nephrology	614 MICHIGAN AVE W	WALKER	MN	Active
DSH240100BW	Child	DSH	Sanford Bemidji Medical Center	SANFORD HEALTH OF NORTHERN MINNESOT - Internal Medicine	614 MICHIGAN AVE W	WALKER	MN	Active
DSH240100BX	Child	DSH	Sanford Bemidji Medical Center	SANFORD HEALTH OF NORTHERN MINNESOT - Orthopedics	614 MICHIGAN AVE W	WALKER	MN	Active
DSH240100BY	Child	DSH	Sanford Bemidji Medical Center	SANFORD HEALTH OF NORTHERN MINNESOT - Surgery	614 MICHIGAN AVE W	WALKER	MN	Active
DSH240100BZ	Child	DSH	Sanford Bemidji Medical Center	SANFORD HEALTH OF NORTHERN MINNESOT - ECHO VASC	614 MICHIGAN AVE W	WALKER	MN	Active
DSH240100C	Child	DSH	Sanford Bemidji Medical Center	Sanford Bemidji Main Clinic	1233 34th Street NW	Bemidji	MN	Terminated
DSH240100CA	Child	DSH	Sanford Bemidji Medical Center	SANFORD HEALTH OF NORTHERN MINNESOT - CARDIOVASCULAR	614 MICHIGAN AVE W	WALKER	MN	Active
DSH240100CB	Child	DSH	Sanford Bemidji Medical Center	SANFORD HEALTH OF NORTHERN MINNESOTA - ORTHOPEDICS - ORTHOPEDICS	110 7th St W	Park Rapids	MN	Terminated
DSH240100CC	Child	DSH	Sanford Bemidji Medical Center	SANFORD HEALTH OF NORTHERN MINNESOTA - SURG - General Surgery	600 S Main Ave	Baudette	MN	Terminated
DSH240100CD	Child	DSH	Sanford Bemidji Medical Center	SANFORD HEALTH OF NORTHERN MINNESOTA - NEPH - Nephrology	110 7th St W	Park Rapids	MN	Terminated
DSH240100CF	Child	DSH	Sanford Bemidji Medical Center	SANFORD HEALTH OF NORTHERN MINNESOTA - OPHTH - Ophthalmology	258 Pine Tree Dr	Big Fork	MN	Terminated
DSH240100CG	Child	DSH	Sanford Bemidji Medical Center	SANFORD HEALTH OF NORTHERN MINNESOTA - EYE INJECT - Ophthalmology	110 7th St W	Park Rapids	MN	Terminated
DSH240100CH	Child	DSH	Sanford Bemidji Medical Center	SANFORD HEALTH OF NORTHERN MINNESOTA - INT PAIN - Interventional Pain	110 7th St W	Park Rapids	MN	Terminated
DSH240100CJ	Child	DSH	Sanford Bemidji Medical Center	SANFORD HEALTH OF NORTHERN MINNESOTA - MED ONC - Medical Oncology	110 7th St W	Park Rapids	MN	Terminated
DSH240100CK	Child	DSH	Sanford Bemidji Medical Center	SANFORD HEALTH OF NORTHERN MINNESOTA - ORTHOPEDICS - Orthopedics	600 S Main Ave	Baudette	MN	Terminated
DSH240100CL	Child	DSH	Sanford Bemidji Medical Center	SANFORD HEALTH OF NORTHERN MINNESOTA - SLEEP - Sleep Clinic	1720 Hwy 59 S	Thief River Falls	MN	Terminated
DSH240100CM	Child	DSH	Sanford Bemidji Medical Center	SANFORD HEALTH OF NORTHERN MINNESOTA - CARDIOLOGY - CARDIOLOGY	614 Michigan Ave W	Walker	MN	Active
DSH240100D	Child	DSH	Sanford Bemidji Medical Center	Sanford Bemidji Sleep Center	3717 Pine Ridge Avenue NW	Bemidji	MN	Active
DSH240100E	Child	DSH	Sanford Bemidji Medical Center	Sanford Bemidji Orthopedic Clinic	1300 Anne Street NW	Bemidji	MN	Terminated
DSH240100F	Child	DSH	Sanford Bemidji Medical Center	Sanford Bemidji Cass Lake Family Medicine	219 Grant Utley Avenue NW	Cass Lake	MN	Active
DSH240100G	Child	DSH	Sanford Bemidji Medical Center	Sanford Bemidji Blackduck Family Medicine	81 1st Street NW	Blackduck	MN	Active
DSH240100H	Child	DSH	Sanford Bemidji Medical Center	Sanford Bemidji 1705 Anne Street Clinic	1705 Anne Street NW	Bemidji	MN	Terminated
DSH240100J	Child	DSH	Sanford Bemidji Medical Center	Sanford Bemidji Eye Center & Optical	1611 Anne Street NW	Bemidji	MN	Terminated
DSH240100K	Child	DSH	Sanford Bemidji Medical Center	SANFORD BEMIDJI Medical Oncology	1233 34th ST NW	BEMIDJI	MN	Active
DSH240100L	Child	DSH	Sanford Bemidji Medical Center	SANFORD BEMIDJI 1611 ANNE ST CLINIC / Walk In Clinic	1611 ANNE ST NW	BEMIDJI	MN	Active
DSH240100M	Child	DSH	Sanford Bemidji Medical Center	SANFORD BEMIDJI 1611 ANNE ST CLINIC / Family Medicine - 1611	1611 ANNE STREET NW	BEMIDJI	MN	Terminated
DSH240100N	Child	DSH	Sanford Bemidji Medical Center	SANFORD BEMIDJI 1611 ANNE ST CLINIC / Pediatrics	1611 ANNE ST NW	BEMIDJI	MN	Active
DSH240100P	Child	DSH	Sanford Bemidji Medical Center	SANFORD BEMIDJI 1611 ANNE ST CLINIC / Dermatology	1611 ANNE ST NW	BEMIDJI	MN	Active
DSH240100Q	Child	DSH	Sanford Bemidji Medical Center	SANFORD BEMIDJI CLINIC / Pain Center	1705 ANNE ST NW	BEMIDJI	MN	Terminated
DSH240100R	Child	DSH	Sanford Bemidji Medical Center	SANFORD BEMIDJI / Podiatry	1300 ANNE ST NW	BEMIDJI	MN	Terminated
DSH240100S	Child	DSH	Sanford Bemidji Medical Center	SANFORD BEMIDJI 1611 ANNE ST CLINIC / Ophthalmology	1611 ANNE ST NW	BEMIDJI	MN	Active
DSH240100T	Child	DSH	Sanford Bemidji Medical Center	SANFORD BEMIDJI MAIN CLINIC / Family Medicine - Main	1233 34TH ST NW	BEMIDJI	MN	Active
DSH240100U	Child	DSH	Sanford Bemidji Medical Center	SANFORD BEMIDJI MAIN CLINIC / Internal Medicine	1233 34TH ST NW	BEMIDJI	MN	Active
DSH240100V	Child	DSH	SANFORD BEMIDJI	SANFORD BEMIDJI / Cardiology	1300 ANNE ST NW	BEMIDJI	MN	Terminated
DSH240100W	Child	DSH	Sanford Bemidji Medical Center	SANFORD BEMIDJI MAIN CLINIC / Nephrology	1233 34TH ST NW	BEMIDJI	MN	Active
DSH240100X	Child	DSH	Sanford Bemidji Medical Center	SANFORD BEMIDJI MAIN CLINIC / Endocrinology	1233 34TH ST NW	BEMIDJI	MN	Active
DSH240100Y	Child	DSH	Sanford Bemidji Medical Center	SANFORD BEMIDJI MAIN CLINIC / Infectious Disease	1233 34TH ST NW	BEMIDJI	MN	Active
DSH240100Z	Child	DSH	Sanford Bemidji Medical Center	SANFORD BEMIDJI MAIN CLINIC / Neurology	1233 34TH ST NW	BEMIDJI	MN	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	8/28/2023 10:21:53 AM	8/22/2024 12:10:32 PM	8/22/2024 12:10 PM
Addresses	Billing Address	Insert	Change Request		Sanford Bemidji Medical Center 1300 ANNE STREET NW BEMIDJI, MN 56601	6/3/2024 11:20 AM
Contacts	Authorizing Official	Update	Profile Change Request	Miller, Lisa Sue Vice President of Finance Sanford Health of Northern Minnesota 2183335523	Miller, Lisa Sue Chief Financial Officer Sanford Health of Northern Minnesota 2183335523	4/25/2024 9:18 AM
Addresses	Shipping Address	Insert	Group Change Request		Sanford Bemidji Medical Center 1300 ANNE STREET NW BEMIDJI, MN 56601	11/16/2023 8:15 AM
Details	Last Recertification Date	Update	Recertification	9/6/2022 12:33:08 PM	8/28/2023 10:21:53 AM	8/28/2023 10:21 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1679677124	3/14/2023 11:50 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		MN	3/14/2023 11:50 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1083933824	3/14/2023 11:50 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		MN	3/14/2023 11:50 PM
Details	Last Recertification Date	Update	Recertification	9/12/2021 12:20:10 PM	9/6/2022 12:33:08 PM	9/6/2022 12:33 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1073166674 (MN)		6/14/2022 12:50 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1982166765	6/14/2022 12:50 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		MN	6/14/2022 12:50 PM
Details	Last Recertification Date	Update	Recertification	8/19/2020 2:11:06 PM	9/12/2021 12:20:10 PM	9/12/2021 12:20 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1669961561 (MN)		6/14/2021 10:32 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1477042372 (MN)		6/14/2021 10:32 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1780628149 (MN)		6/14/2021 10:32 PM
Contacts	Primary Contact	Update	Change Request	Eischens, Karla P Director of Pharmacy Sanford Health of Northern Minnesota 2183335543	Webb, Matthew Aaron Director of Pharmacy Sanford Health of Northern Minnesota 2183336339	6/9/2021 11:49 AM
Medicaid Billing	NPI: State	Update	Recertification		MN	8/19/2020 2:11 PM
Medicaid Billing	NPI: State	Update	Recertification		MN	8/19/2020 2:11 PM
Medicaid Billing	NPI: State	Update	Recertification		MN	8/19/2020 2:11 PM
Medicaid Billing	NPI: State	Update	Recertification		MN	8/19/2020 2:11 PM
Medicaid Billing	NPI: State	Update	Recertification		MN	8/19/2020 2:11 PM
Details	Last Recertification Date	Update	Recertification	8/21/2019 9:18:22 AM	8/19/2020 2:11:06 PM	8/19/2020 2:11 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1982166765 ( )		6/15/2020 10:10 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1679677124 ( )		6/15/2020 10:10 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1083933824 ( )		6/15/2020 10:10 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/12/2020 11:03 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		314545001	6/12/2020 11:03 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		MN	6/12/2020 11:03 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1679677124	6/11/2020 10:32 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1669961561	6/11/2020 10:32 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1083933824	6/11/2020 10:32 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1477042372	6/11/2020 10:32 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1982166765	2/18/2020 9:38 AM
Contacts	Authorizing Official	Update	Change Request	Johnson, Joy Ellen Vice President of Operations Sanford Health of Northern Minnesota 2183336422	Miller, Lisa Sue Vice President of Finance Sanford Health of Northern Minnesota 2183335523	12/4/2019 4:12 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1073166674	11/20/2019 7:42 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1801870191	10/8/2019 8:02 AM
Details	Last Recertification Date	Update	Recertification	8/21/2018 4:47:08 PM	8/21/2019 9:18:22 AM	8/21/2019 9:18 AM
Contacts	Authorizing Official	Update	Change Request	BOYER, CRAIG O. Vice President of Finance Sanford Health of Northern Minnesota 2183335508	Johnson, Joy Ellen Vice President of Operations Sanford Health of Northern Minnesota 2183336422	6/7/2019 1:15 PM
Details	Last Recertification Date	Update	Recertification	11/19/2017 11:39:55 AM	8/21/2018 4:47:08 PM	8/21/2018 4:47 PM
Details	Entity Name	Update	Recertification	SANFORD BEMIDJI	Sanford Bemidji Medical Center	11/20/2017 7:58 AM
Details	Last Recertification Date	Update	Recertification	8/19/2016 12:00:00 AM	11/19/2017 11:39:55 AM	11/19/2017 11:39 AM
Contacts	Authorizing Official	Update	Profile Change Request	BOYER, CRAIG O. CFO Sanford Health of Northern Minnesota 2183335508	BOYER, CRAIG O. Vice President of Finance Sanford Health of Northern Minnesota 2183335508	10/18/2017 1:24 PM
Contacts	Signed By	Update	Profile Change Request	BOYER, CRAIG O. CFO Sanford Health of Northern Minnesota 2183335508	BOYER, CRAIG O. Vice President of Finance Sanford Health of Northern Minnesota 2183335508	10/18/2017 1:24 PM
Contacts	Authorizing Official	Update		BOYER, CRAIG O. CFO 2183335508	BOYER, CRAIG O. CFO Sanford Health of Northern Minnesota 2183335508	10/9/2017 11:03 AM
Contacts	Signed By	Update		BOYER, CRAIG O. CFO 2183335508	BOYER, CRAIG O. CFO Sanford Health of Northern Minnesota 2183335508	10/9/2017 11:03 AM
Contacts	Primary Contact	Update		Eischens, Karla Director of Pharmacy 2183335543	Eischens, Karla P Director of Pharmacy Sanford Health of Northern Minnesota 2183335543	9/27/2017 12:52 PM
Contacts	Primary Contact	Insert			Eischens, Karla Director of Pharmacy 2183335543	7/26/2017 4:41 PM
Contacts	Authorizing Official	Insert			BOYER, CRAIG O. CFO 2183335508	7/26/2017 4:41 PM
Contacts	Signed By	Insert			BOYER, CRAIG O. CFO 2183335508	7/26/2017 4:41 PM
Addresses	Main Address	Insert			1233 34TH ST NW BEMIDJI, MN 56601-5112	7/26/2017 4:41 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/14/2017 11:50 AM
Medicaid Billing	Medicaid: Number	Insert			314545000	4/14/2017 11:50 AM
Medicaid Billing	Medicaid: State	Insert			MN	4/14/2017 11:50 AM
Medicaid Billing	NPI: Number	Insert			1780628149	4/14/2017 11:50 AM
Details	Last Recertification Date	Update		8/12/2015 12:00:00 AM	8/19/2016 12:00:00 AM	8/19/2016 2:07 PM
Details	Last Recertification Date	Update			8/12/2015 12:00:00 AM	8/25/2015 4:38 PM
Dates	Participating Approval Date	Update			3/11/2015 12:00:00 AM	3/11/2015 2:06 PM
Details	State	Update		Pending	Active	3/11/2015 2:06 PM
Dates	Start Date	Update			4/1/2015 12:00:00 AM	3/11/2015 2:06 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_49791	DSH240100U	1/27/2015 8:30 AM
Details	340B ID	Update			OUTPATIENT_ONLINE_REG_49791	1/15/2015 12:44 PM
Details	Last Recertification Date	Insert				1/15/2015 12:44 PM
Details	Grant Number	Insert				1/15/2015 12:44 PM
Details	340B ID	Insert				1/15/2015 12:44 PM
Details	Is Authorizing Official EHB Data	Insert				1/15/2015 12:44 PM
Dates	Last Date That 340B Drugs Purchased	Insert				1/15/2015 12:44 PM
Details	Medicare Provider Number	Insert			240100	1/15/2015 12:44 PM
Details	Entity Name	Insert			SANFORD BEMIDJI	1/15/2015 12:44 PM
Details	Program Code	Insert			DSH	1/15/2015 12:44 PM
Details	Entity Subname	Insert			SANFORD BEMIDJI MAIN CLINIC / Internal Medicine	1/15/2015 12:44 PM
Dates	Participating Approval Date	Insert				1/15/2015 12:44 PM
Details	State	Insert			Pending	1/15/2015 12:44 PM
Dates	Registration Date	Insert			1/15/2015 12:00:00 AM	1/15/2015 12:44 PM
Dates	Signed By Date	Insert			1/15/2015 12:00:00 AM	1/15/2015 12:44 PM
Dates	Start Date	Insert				1/15/2015 12:44 PM
Terminations	Termination Comments	Insert				1/15/2015 12:44 PM
Terminations	Termination Date	Insert				1/15/2015 12:44 PM
Terminations	Termination Effective Date	Insert				1/15/2015 12:44 PM
Terminations	Termination Reason	Insert				1/15/2015 12:44 PM