Covered Entity Details

DSH350011AC SANFORD MEDICAL CENTER FARGO (Active) - information as of 4/25/2025 6:35:33 PM

Main Details

Name

SANFORD MEDICAL CENTER FARGO

Subdivision Name

Sanford Medical Center Fargo / Sanford South University Speech Therapy

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH350011AC

Medicare Provider Number

350011

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

1/5/2017

Participating Start Date

4/1/2017

Participating Approval Date

3/3/2017

Last Recertification Date

9/5/2024

Contacts

Authorizing Official

Sanford Medical Center Fargo
Kristin Herrmann, Vice President, Finance
(701) 417-2326

Primary Contact

Sanford Health
Jesse Breidenbach, Vice President, Pharmacy
(701) 234-6887

Addresses

Street Address

1720 South University Drive
Fargo, ND 58103

Billing Address
Same as Street Address

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
ND	1457315	1528009412
MN	1528009412,1861927709,1558458844	1528009412,1861927709,1558458844,1124122783,1235173519,1295374288,1568789121

Shipping Addresses

Shipping Address 1

Sanford Medical Center Fargo
801 Broadway N
Fargo, ND 58102

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
DSH350011A	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford Broadway Medical Building / Sanford Cardiac Rehab	736 Broadway North	Fargo	ND	Active
DSH350011AA	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford Medical Center Fargo / Sanford South University Radiology CT	1720 South University Drive	Fargo	ND	Active
DSH350011AB	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford Medical Center Fargo / Sanford South University Occupational Therapy	1720 South University Drive	Fargo	ND	Active
DSH350011AC	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford Medical Center Fargo / Sanford South University Speech Therapy	1720 South University Drive	Fargo	ND	Active
DSH350011AD	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford Medical Center Fargo / Sanford South University Physical Therapy	1720 South University Drive	Fargo	ND	Active
DSH350011AE	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford Medical Center Fargo / Sanford South University Respiratory Therapy	1720 South University Drive	Fargo	ND	Active
DSH350011AF	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford Orthopedics Sport Medicine / Sanford Pain Services	2301 25th St S	Fargo	ND	Active
DSH350011AG	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford Broadway Medical Building / Sanford Coordinated Treatment Center - Brain Injury Adult	736 Broadway North	Fargo	ND	Terminated
DSH350011AH	Child	DSH	SANFORD MEDICAL CENTER - FARGO	Sanford Broadway Medical Building / Sanford Coordinated Treatment Center - Cancer Survivorship	736 Broadway North	Fargo	ND	Terminated
DSH350011AJ	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford Broadway Medical Building / Sanford Coordinated Treatment Center - Cerebral Palsy	736 Broadway North	Fargo	ND	Terminated
DSH350011AK	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford Broadway Medical Building / Sanford Coordinated Treatment Center - Child Brain Injury	736 Broadway North	Fargo	ND	Terminated
DSH350011AL	Child	DSH	SANFORD MEDICAL CENTER - FARGO	Sanford Broadway Medical Building / Sanford Coordinated Treatment Center - Children's Weight Management	736 Broadway North	Fargo	ND	Terminated
DSH350011AM	Child	DSH	SANFORD MEDICAL CENTER - FARGO	Sanford Broadway Medical Building / Sanford Coordinated Treatment Center - Cystic Fibrosis	736 Broadway North	Fargo	ND	Terminated
DSH350011AN	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford Broadway Medical Building / Sanford Coordinated Treatment Center - Diabetes Peds	736 Broadway North	Fargo	ND	Terminated
DSH350011AP	Child	DSH	SANFORD MEDICAL CENTER - FARGO	Sanford Broadway Medical Building / Sanford Coordinated Treatment Center - Downs Syndrome	736 Broadway North	Fargo	ND	Terminated
DSH350011AQ	Child	DSH	SANFORD MEDICAL CENTER - FARGO	Sanford Broadway Medical Building / Sanford Coordinated Treatment Center - Feeding/Swallowing	736 Broadway North	Fargo	ND	Terminated
DSH350011AR	Child	DSH	SANFORD MEDICAL CENTER - FARGO	Sanford Broadway Medical Building / Sanford Coordinated Treatment Center - Growth/Development	736 Broadway North	Fargo	ND	Terminated
DSH350011AS	Child	DSH	SANFORD MEDICAL CENTER - FARGO	Sanford Broadway Medical Building / Sanford Coordinated Treatment Center - Huntingtons Disease	736 Broadway North	Fargo	ND	Terminated
DSH350011AT	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford Broadway Medical Building / Sanford Coordinated Treatment Center - Metabolic Service	736 Broadway North	Fargo	ND	Active
DSH350011AU	Child	DSH	SANFORD MEDICAL CENTER - FARGO	Sanford Broadway Medical Building / Sanford Coordinated Treatment Center - Multiple Sclerosis	736 Broadway North	Fargo	ND	Terminated
DSH350011AV	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford Broadway Medical Building / Sanford Coordinated Treatment Center - Muscular Dystrophy Association	736 Broadway North	Fargo	ND	Active
DSH350011AW	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford Broadway Medical Building / Sanford Coordinated Treatment Center Myelodysplasia	736 Broadway North	Fargo	ND	Active
DSH350011AX	Child	DSH	SANFORD MEDICAL CENTER - FARGO	Sanford Broadway Medical Building / Sanford Coordinated Treatment Center - Palliative Care	736 Broadway North	Fargo	ND	Terminated
DSH350011AY	Child	DSH	SANFORD MEDICAL CENTER - FARGO	Sanford Broadway Medical Building / Sanford Coordinated Treatment Center - Parkinsons Disease	736 Broadway North	Fargo	ND	Terminated
DSH350011AZ	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford Broadway Medical Building / Sanford Coordinated Treatment Center - Peds Development	736 Broadway North	Fargo	ND	Terminated
DSH350011B	Child	DSH	SANFORD MEDICAL CENTER FARGO	SANFORD WEST FARGO CLINIC / Sanford Radiology West Fargo PBB	1220 SHEYENNE ST	WEST FARGO	ND	Terminated
DSH350011BA	Child	DSH	SANFORD MEDICAL CENTER - FARGO	Sanford Broadway Medical Building / Sanford Coordinated Treatment Center - Spinal Cord	736 Broadway North	Fargo	ND	Terminated
DSH350011BB	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford Broadway Medical Building / Sanford Infectious Disease Travel Clinic PBB	736 Broadway North	Fargo	ND	Active
DSH350011BC	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford Broadway Medical Building / Sanford Nephrology PBB	736 Broadway North	Fargo	ND	Active
DSH350011BD	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford Broadway Medical Building / Sanford Physical Medicine PBB	736 Broadway North	Fargo	ND	Active
DSH350011BE	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford Broadway Medical Building / Sanford Transplant Surgery PBB	736 Broadway North	Fargo	ND	Active
DSH350011BF	Child	DSH	SANFORD MEDICAL CENTER FARGO	SANFORD CHILDREN'S SW CLINIC / Sanford Pediatric Sleep PBB	3955 S 56TH ST Ste D	Fargo	ND	Active
DSH350011BG	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford Children's SW Clinic / Sanford Radiology Southwest Pediatrics PBB	2701 13TH AVE S	FARGO	ND	Active
DSH350011BH	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford Children's SW Clinic / Sanford Southwest Pediatrics PBB	2701 13TH AVE S	FARGO	ND	Active
DSH350011BJ	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford Children's SW Clinic / Sanford Southwest Peds Urgent Care PBB	2701 13TH AVE S	FARGO	ND	Active
DSH350011BK	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford Dermatology & Laser Clinic / Sanford Dermatology PBB	4656 40th Ave S	Fargo	ND	Active
DSH350011BL	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford Hawley Clinic / Sanford Hawley General PBB	1412 Main Street	Hawley	MN	Active
DSH350011BM	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford Medical Center Fargo / Radiology Diagnostic	5225 23rd Ave S	Fargo	ND	Active
DSH350011BN	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford Medical Center Fargo / Radiology Intervention	5225 23rd Ave S	Fargo	ND	Active
DSH350011BP	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford Medical Center Fargo / Sanford Anthesiology PBB	5225 23rd Ave S	Fargo	ND	Active
DSH350011BQ	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford Medical Center Fargo / Sanford Cardiac Cath Lab	5225 23rd Ave S	Fargo	ND	Active
DSH350011BR	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford Medical Center Fargo / Sanford Emergency Center	5225 23rd Ave S	Fargo	ND	Active
DSH350011BS	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford Medical Center Fargo / Sanford Plastic Surgery PBB	2801 S UNIVERSITY DR	FARGO	ND	Active
DSH350011BT	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford Medical Center Fargo / Sanford Sleep Center PBB	2801 S UNIVERSITY DR	FARGO	ND	Active
DSH350011BU	Child	DSH	SANFORD MEDICAL CENTER FARGO	SANFORD MEDICAL CENTER FARGO / Sanford Sleep Lab	2801 S UNIVERSITY DR	FARGO	ND	Active
DSH350011BV	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford Medical Center Fargo / Sanford South University Day Unit, PACU, Intra-OP	1720 South University Drive	Fargo	ND	Active
DSH350011BW	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford Medical Center Fargo / Sanford South University Eating Disorder Unit Partial Hospitalization Program	1720 South University Drive	Fargo	ND	Terminated
DSH350011BX	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford Medical Center Fargo / Sanford South University Operating Room	1720 South University Drive	Fargo	ND	Active
DSH350011BY	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford Medical Center Fargo / Sanford South University Partial Psych	1711 South University Drive	Fargo	ND	Active
DSH350011BZ	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford Medical Center Fargo / Sanford South University Post Anesthesia Care Unit	1720 South University Drive	Fargo	ND	Terminated
DSH350011C	Child	DSH	SANFORD MEDICAL CENTER FARGO	SANFORD WEST FARGO CLINIC / Sanford West Fargo OB/GYN PBB	1220 SHEYENNE ST	WEST FARGO	ND	Active
DSH350011CA	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford Medical Center Fargo / Sanford Trauma Center	5225 23rd Ave S	Fargo	ND	Active
DSH350011CB	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford Moorhead Clinic / Sanford Adult Psychiatry PBB	4000 28th Ave South	Moorhead	MN	Active
DSH350011CC	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford Moorhead Clinic / Sanford Adult Psychology PBB	4000 28th Ave S	MOORHEAD	MN	Active
DSH350011CD	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford Moorhead Clinic / Family Medicine PBB	4000 28TH AVE S	MOORHEAD	MN	Active
DSH350011CE	Child	DSH	SANFORD MEDICAL CENTER FARGO	SANFORD MOORHEAD CLINIC / Sanford Moorhead Super Clinic OB/GYN PBB	4000 28TH AVE S	MOORHEAD	MN	Active
DSH350011CF	Child	DSH	SANFORD MEDICAL CENTER FARGO	SANFORD MOORHEAD CLINIC / Sanford Moorhead Pediatrics PBB	4000 28TH AVE S	MOORHEAD	MN	Active
DSH350011CG	Child	DSH	SANFORD MEDICAL CENTER FARGO	SANFORD MOORHEAD CLINIC / Sanford Radiology Moorhead PBB	4000 28TH AVE S	MOORHEAD	MN	Terminated
DSH350011CH	Child	DSH	SANFORD MEDICAL CENTER FARGO	SANFORD MOORHEAD CLINIC / Internal Medicine PBB	4000 28TH AVE S	MOORHEAD	MN	Active
DSH350011CJ	Child	DSH	SANFORD MEDICAL CENTER FARGO	SANFORD NEUROSCIENCE CLINIC / Sanford Neurology PBB	2301 25th St S	Fargo	ND	Active
DSH350011CK	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford North Fargo Clinic / Sanford Radiology North Fargo PBB	2601 Broadway North	Fargo	ND	Terminated
DSH350011CL	Child	DSH	SANFORD MEDICAL CENTER FARGO	SANFORD NEUROSCIENCE CLINIC / Sanford Neurosurgery PBB	2301 25th St S	Fargo	ND	Active
DSH350011CM	Child	DSH	SANFORD MEDICAL CENTER FARGO	SANFORD NEUROSCIENCE CLINIC / Sanford Radiology Neuroscience PBB	2301 25th St S	Fargo	ND	Terminated
DSH350011CN	Child	DSH	SANFORD MEDICAL CENTER FARGO	SANFORD NEUROSCIENCE CLINIC / Sanford Spine Rehabilitation	700 1ST AVE S	FARGO	ND	Terminated
DSH350011CP	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford North Fargo Clinic / Sanford North Fargo Family Medicine PBB	2601 Broadway North	Fargo	ND	Active
DSH350011CQ	Child	DSH	SANFORD MEDICAL CENTER FARGO	SANFORD ORTHOPEDICS SPORTS MEDICINE / Sanford Hand Surgery PBB	1720 South University Drive	Fargo	ND	Active
DSH350011CR	Child	DSH	SANFORD MEDICAL CENTER FARGO	SANFORD ORTHOPEDICS SPORTS MEDICINE / Sanford Orthopedic Clinic PBB	1720 South University Drive	Fargo	ND	Active
DSH350011CS	Child	DSH	SANFORD MEDICAL CENTER - FARGO	SANFORD ORTHOPEDICS SPORTS MEDICINE / Sanford Orthopedic Surgery Center	2301 25TH ST S	FARGO	ND	Terminated
DSH350011CT	Child	DSH	SANFORD MEDICAL CENTER - FARGO	SANFORD ORTHOPEDICS SPORTS MEDICINE / Sanford Orthopedic Surgery Center Post Anesthesia Care Unit	2301 25TH ST S	FARGO	ND	Terminated
DSH350011CU	Child	DSH	SANFORD MEDICAL CENTER FARGO	SANFORD ORTHOPEDICS SPORTS MEDICINE / Sanford Radiology MRI	2301 25TH ST S	FARGO	ND	Active
DSH350011CV	Child	DSH	SANFORD MEDICAL CENTER FARGO	SANFORD ORTHOPEDICS SPORTS MEDICINE / Sanford Radiology Orthopedic/Sports Medicine PBB	1720 South University Drive	Fargo	ND	Active
DSH350011CW	Child	DSH	SANFORD MEDICAL CENTER FARGO	SANFORD PROFESSIONAL BUILDING / Sanford Child Psychiatry PBB	100 4TH ST S	FARGO	ND	Active
DSH350011CX	Child	DSH	SANFORD MEDICAL CENTER FARGO	SANFORD PROFESSIONAL BUILDING / Sanford Child Psychology PBB	100 4TH ST S	FARGO	ND	Active
DSH350011CY	Child	DSH	SANFORD MEDICAL CENTER FARGO	SANFORD PROFESSIONAL BUILDING / Sanford Children's Care Clinic PBB	100 4TH ST S	FARGO	ND	Active
DSH350011CZ	Child	DSH	SANFORD MEDICAL CENTER FARGO	SANFORD PROFESSIONAL BUILDING / Sanford Neuropsychology PBB	100 4TH ST S	FARGO	ND	Active
DSH350011D	Child	DSH	SANFORD MEDICAL CENTER FARGO	SANFORD WEST FARGO CLINIC / Sanford West Fargo Family Medicine PBB	1220 SHEYENNE ST	WEST FARGO	ND	Active
DSH350011DA	Child	DSH	SANFORD MEDICAL CENTER FARGO	SANFORD REPRODUCTIVE MEDICINE CLINIC / Sanford Radiology Reproductive Medicine PBB	1111 HARWOOD DR S	FARGO	ND	Terminated
DSH350011DB	Child	DSH	SANFORD MEDICAL CENTER FARGO	SANFORD REPRODUCTIVE MEDICINE CLINIC / Sanford Reproductive Medicine PBB	1111 HARWOOD DR S	FARGO	ND	Active
DSH350011DC	Child	DSH	SANFORD MEDICAL CENTER FARGO	SANFORD ROGER MARIS CANCER CENTER / Sanford Infusion Center PBB	820 4TH ST N	FARGO	ND	Active
DSH350011DD	Child	DSH	SANFORD MEDICAL CENTER FARGO	SANFORD ROGER MARIS CANCER CENTER / Sanford Medical Oncology PBB	820 4TH ST N	FARGO	ND	Active
DSH350011DE	Child	DSH	SANFORD MEDICAL CENTER FARGO	SANFORD ROGER MARIS CANCER CENTER / Sanford Pediatric Oncology PBB	820 4TH ST N	FARGO	ND	Active
DSH350011DF	Child	DSH	SANFORD MEDICAL CENTER FARGO	SANFORD ROGER MARIS CANCER CENTER / Sanford Radiation Oncology	820 4TH ST N	FARGO	ND	Active
DSH350011DG	Child	DSH	SANFORD MEDICAL CENTER FARGO	SANFORD ROGER MARIS CANCER CENTER / Sanford Radiation Oncology PBB	820 4TH ST N	FARGO	ND	Active
DSH350011DH	Child	DSH	SANFORD MEDICAL CENTER FARGO	SANFORD ROGER MARIS CANCER CENTER / Sanford Radiation Physics	820 4TH ST N	FARGO	ND	Active
DSH350011DJ	Child	DSH	SANFORD MEDICAL CENTER - FARGO	Sanford Same Day Surgery Center / Same Day Surgery	321 8th Avenue North	Fargo	ND	Terminated
DSH350011DK	Child	DSH	SANFORD MEDICAL CENTER - FARGO	Sanford Same Day Surgery Center / Sanford Same Day Surgery Post Anesthesia Care Unit	321 8th Avenue North	Fargo	ND	Terminated
DSH350011DL	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford South University - 1711 Medical Building / Sanford South University Partial Psych Child	1711 South University Drive	Fargo	ND	Active
DSH350011DM	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford South University - 1717 Medical Building / Sanford Bariatric Surgery PBB	1717 South University Drive	Fargo	ND	Active
DSH350011DN	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford South University - 1717 Medical Building / Sanford Eating Disorders PBB	1717 South University Drive	Fargo	ND	Active
DSH350011DP	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford South University - 1717 Medical Building / Sanford Oral Surgery PBB	1717 South University Drive	Fargo	ND	Active
DSH350011DQ	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford South University - 1717 Medical Building / Sanford South University Eye Operating Room	1717 South University	Fargo	ND	Active
DSH350011DR	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford South University - 1717 Medical Building / Sanford South University Eye Post Anesthesia Care Unit	1717 South University Drive	Fargo	ND	Terminated
DSH350011DS	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford South University / Sanford South University Eye Services PBB	1717 South University Drive	Fargo	ND	Active
DSH350011DT	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford South University - 1717 Medical Building / Sanford South University Feeding Disorders Partial Hospital Program	1717 South University Drive	Fargo	ND	Active
DSH350011DU	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford South University / Sanford South University Eye Services MDs PBB	1717 South University Drive	Fargo	ND	Active
DSH350011DV	Child	DSH	SANFORD MEDICAL CENTER FARGO	SANFORD SOUTH UNIVERSITY URGENT CARE / Sanford South University Urgent Care PBB	1720 S UNIVERSITY DR	FARGO	ND	Active
DSH350011DW	Child	DSH	SANFORD MEDICAL CENTER - FARGO	Sanford Medical Center Fargo / Sanford Infusions South University 4A	1720 South University Drive	Fargo	ND	Terminated
DSH350011DX	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford Medical Center Fargo / Sanford South University 4A Medical Ortho Surgical	1720 South University Drive	Fargo	ND	Active
DSH350011DZ	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford Medical Center Fargo / Sanford Cardiovasular Diagnostics	5225 23rd Ave S	Fargo	ND	Active
DSH350011E	Child	DSH	SANFORD MEDICAL CENTER FARGO	SANFORD SOUTHPOINTE CLINIC / Sanford Radiology Southpointe PBB	2400 32ND AVE S	FARGO	ND	Terminated
DSH350011EA	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford Medical Center Fargo / Sanford Vascular Surgery	5225 23rd Ave S	Fargo	ND	Active
DSH350011EB	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford Medical Center Fargo / Sanford Urology	5225 23rd Ave S	Fargo	ND	Terminated
DSH350011EC	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford Medical Center Fargo / Sanford Cardiovascular Surgery	5225 23rd Ave S	Fargo	ND	Active
DSH350011ED	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford Medical Center Fargo / Sanford Surgery PBB	5225 23rd Ave S	Fargo	ND	Active
DSH350011EG	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford Medical Center Fargo / Ultrasound Provider Based Billing	5225 23rd Ave S	Fargo	ND	Active
DSH350011EH	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford Medical Center Fargo / Sanford Cardiology PBB	5225 23rd Ave S	Fargo	ND	Active
DSH350011EJ	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford Medical Center Fargo Observation Beds / Sanford Critical Care	5225 23rd Ave S	Fargo	ND	Active
DSH350011EK	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford Medical Center Fargo / Sanford Cardiology Observation Bed	5225 23rd Ave S	Fargo	ND	Active
DSH350011EL	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford Medical Center Fargo Observation Bed / Sanford Pediatric Intensive Care Unit Child Hospital	5225 23rd Ave S	Fargo	ND	Active
DSH350011EM	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford Medical Center Fargo Observation Bed / Sanford Family Birth Center	5225 23rd Ave S	Fargo	ND	Active
DSH350011EN	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford Medical Center Fargo / Sanford Pediatrics Observation Bed	5225 23rd Ave S	Fargo	ND	Active
DSH350011EP	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford Medical Center Fargo / Sanford Clinical Decision Unit	5225 23rd Ave S	Fargo	ND	Active
DSH350011EQ	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford Medical Center Fargo Observation Bed / Sanford Neuro/Surgical	5225 23rd Ave S	Fargo	ND	Active
DSH350011ER	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford Medical Center Fargo Observation Bed / Sanford Medical/Surgical	5225 23rd Ave S	Fargo	ND	Active
DSH350011ES	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford Medical Center Fargo / Sanford Maternal Fetal Medicine	5225 23rd Ave S	Fargo	ND	Active
DSH350011ET	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford Medical Center Fargo / Sanford OB/GYN	5225 23rd Ave S	Fargo	ND	Active
DSH350011EU	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford Medical Center Fargo / Respiratory Therapy	5225 23rd Ave S	Fargo	ND	Active
DSH350011EV	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford Roger Maris Cancer / Radiation Oncology Imaging and Simulation	820 4th St N	Fargo	ND	Terminated
DSH350011EW	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford Medical Center Fargo / Endoscopy	5225 23rd Ave S	Fargo	ND	Active
DSH350011EX	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford Medical Center Fargo / Ultrasound	5225 23rd Ave S	Fargo	ND	Active
DSH350011EY	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford Medical Center Fargo / CT Scan	5225 23rd Ave S	Fargo	ND	Active
DSH350011EZ	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford Medical Center Fargo / Heart Stress Tests	5225 23rd Ave S	Fargo	ND	Active
DSH350011F	Child	DSH	SANFORD MEDICAL CENTER FARGO	SANFORD SOUTHPOINTE CLINIC / Sanford Southpointe Nutrition Therapy PBB	2400 32ND AVE S	FARGO	ND	Active
DSH350011FA	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford Medical Center Fargo / Echocardiology	5225 23rd Ave S	Fargo	ND	Active
DSH350011FB	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford Medical Center Fargo / Nuclear Medicine	5225 23rd Ave S	Fargo	ND	Active
DSH350011FC	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford Medical Center Fargo / Endoscopy	321 8th Ave N	Fargo	ND	Active
DSH350011FD	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford Medical Center Fargo / Open MRI Institute Of Diagnostic Imaging	2829 S University Dr	Fargo	ND	Active
DSH350011FE	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford Medical Center Fargo / Peds ARU	5225 23rd Ave S	Fargo	ND	Active
DSH350011FF	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford Medical Center Fargo / Admissions/Recovery Unit	5225 23rd Ave S	Fargo	ND	Active
DSH350011FG	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford Medical Center Fargo / Operating Room	5225 23rd Ave S	Fargo	ND	Active
DSH350011FH	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford Medical Center Fargo / Post Anesthesia Care Unit	5225 23rd Ave S	Fargo	ND	Active
DSH350011FJ	Child	DSH	SANFORD MEDICAL CENTER - FARGO	Sanford Medical Center Fargo / 5A SMCF	5225 23rd Ave S	Fargo	ND	Terminated
DSH350011FK	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford Medical Center Fargo / 5D Intermediate Care	5225 23rd Ave S	Fargo	ND	Active
DSH350011FL	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford Medical Center Fargo / Peds Gastro PBB	5225 23rd Ave S	Fargo	ND	Active
DSH350011FM	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford Medical Center Fargo / 4C Ortho - SU	1720 South University Drive	Fargo	ND	Active
DSH350011FN	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford Broadway Medical Building / Sanford Coordinated Treatment Center	736 Broadway North	Fargo	ND	Active
DSH350011FP	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford Medical Center Fargo / Trauma PBB	5225 23rd Ave S	Fargo	ND	Active
DSH350011FQ	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford Medical Center Fargo / EEG	5225 23rd Ave S	Fargo	ND	Active
DSH350011FR	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford Medical Center Fargo / Peds Surgery PBB	5225 23rd Ave S	Fargo	ND	Active
DSH350011FS	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford Medical Center Fargo / Gastroenterology PBB	5225 23rd Ave S	Fargo	ND	Active
DSH350011FT	Child	DSH	SANFORD MEDICAL CENTER FARGO	SANFORD ROGER MARIS CANCER CENTER / Psych Oncology PBB	820 4th St N	Fargo	ND	Active
DSH350011FU	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford Medical Center Fargo / EEG SU	1720 South University Drive	Fargo	ND	Terminated
DSH350011FV	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford Orthopedics Sport Medicine / Pain Services Professional PBB	2301 25th St S	Fargo	ND	Active
DSH350011FW	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford Medical Center Fargo / I94 Clinic	5225 23rd Ave S	Fargo	ND	Terminated
DSH350011FX	Child	DSH	SANFORD MEDICAL CENTER FARGO	SANFORD SOUTH UNIVERSITY / Sanford South University Feeding Disorders	1717 South University Drive	Fargo	ND	Terminated
DSH350011FY	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford Medical Center Fargo / Sanford Medical Center Fargo Pulmonary Diagnostics	5225 23rd Ave S	Fargo	ND	Active
DSH350011FZ	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford Medical Center Fargo / Sanford Diabetes Education PBB - Sanford Diabetes Education PBB	1220 Sheyenne St	West Fargo	ND	Active
DSH350011G	Child	DSH	SANFORD MEDICAL CENTER FARGO	SANFORD SOUTHPOINTE CLINIC / Sanford Southpointe Diabetes Education PBB	2400 32ND AVE S	FARGO	ND	Active
DSH350011GA	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford Medical Center Fargo / Sanford Diabetes Education PBB - Sanford Diabetes Education PBB	4000 28th Avenue South	Moorhead	MN	Active
DSH350011GB	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford Medical Center Fargo / Sanford Nutrition Therapy PBB - Sanford Nutrition Therapy PBB	4000 28th Avenue South	Moorhead	MN	Active
DSH350011GC	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford Medical Center Fargo / Sanford Pediatric Oncology I94 - Sanford Pediatric Oncology I94	5225 23rd Ave S	Fargo	ND	Active
DSH350011GD	Child	DSH	SANFORD MEDICAL CENTER FARGO	BROADWAY CLINIC NUTRITION THERAPY - CLINICAL NUTRITION 1200.57010 1534800913	736 Broadway North	FARGO	ND	Active
DSH350011GE	Child	DSH	SANFORD MEDICAL CENTER FARGO	PEDIATRICS THERAPIES - SPEECH THERAPY	2400 32 AVE S	FARGO	ND	Active
DSH350011GF	Child	DSH	SANFORD MEDICAL CENTER FARGO	PEDIATRICS WEST FARGO CLINIC - PEDIATRICS 1200.53075	1220 Sheyenne St	WEST FARGO	ND	Active
DSH350011GG	Child	DSH	SANFORD MEDICAL CENTER FARGO	INTEGRATIVE INTERNAL MEDICINE FARGO - INTEGRATIVE INTERNAL MEDICINE 1200.53232	2400 32 AVE S	FARGO	ND	Terminated
DSH350011GH	Child	DSH	SANFORD MEDICAL CENTER FARGO	PEDIATRICS THERAPIES - PHYSICAL THERAPY 1200.42680	2400 32 AVE S	FARGO	ND	Active
DSH350011GJ	Child	DSH	SANFORD MEDICAL CENTER FARGO	PEDIATRICS THERAPIES - OCCUPATIONAL THERAPY 1200.42680	2400 32 AVE S	FARGO	ND	Terminated
DSH350011GK	Child	DSH	SANFORD MEDICAL CENTER FARGO	PEDIATRIC NEPHROLOGY WEST FARGO CLINIC - PEDIATRIC NEPHROLOGY 1200.53075	1220 Sheyenne St	WEST FARGO	ND	Active
DSH350011GL	Child	DSH	SANFORD MEDICAL CENTER FARGO	SOUTHWEST PEDIATRICS CLINIC NUTRITION THERAPY - CLINICAL NUTRITION 1200.57010 1534800912	2701 13 AVE S	FARGO	ND	Active
DSH350011GM	Child	DSH	SANFORD MEDICAL CENTER FARGO	FAMILY MEDICINE VETERANS SQUARE CLINIC - FAMILY MEDICINE 1200.53255	3955 56th St S Ste D	FARGO	ND	Active
DSH350011GN	Child	DSH	SANFORD MEDICAL CENTER FARGO	INTERNAL MEDICINE GENETICS CLINIC - INTERNAL MEDICINE GENETICS 1200.54100	2400 32 AVE S	FARGO	ND	Terminated
DSH350011GP	Child	DSH	SANFORD MEDICAL CENTER FARGO	CHIROPRACTIC REPRODUCTIVE MEDICINE CLINIC - CHIROPRACTIC REPRODUCTIVE MEDICINE 1200.54120	1111 Harwood Dr S	FARGO	ND	Active
DSH350011GQ	Child	DSH	SANFORD MEDICAL CENTER FARGO	DIABETIC EDUCATORS SOUTH UNIVERSITY CLINIC - DIABETIC EDUCATORS 1200.57005	1717 South University Drive	FARGO	ND	Active
DSH350011GR	Child	DSH	SANFORD MEDICAL CENTER FARGO	SOUTHPOINTE NUTRITION THERAPY INTEGRATIVE MEDICINE - CLINICAL NUTRITION 1200.57010 1534800917	2400 32 AVE S	FARGO	ND	Active
DSH350011GS	Child	DSH	SANFORD MEDICAL CENTER FARGO	WEST FARGO CLINIC NUTRITION THERAPY - CLINICAL NUTRITION 1200.57010 1534800908	1220 Sheyenne St	WEST FARGO	ND	Active
DSH350011GT	Child	DSH	SANFORD MEDICAL CENTER FARGO	PEDIATRICS VETERANS SQUARE - PEDIATRICS CLINIC 1200.53060	3955 56th St S Ste D	FARGO	ND	Active
DSH350011GU	Child	DSH	SANFORD MEDICAL CENTER FARGO	INTEGRATIVE FAMILY MEDICINE FARGO - INTEGRATIVE FAMILY MEDICINE 1200.53232	2400 32nd Ave S	FARGO	ND	Active
DSH350011GV	Child	DSH	SANFORD MEDICAL CENTER FARGO	SOUTH UNIVERSITY CLINIC NUTRITION THERAPY - CLINICAL NUTRITION 1200.57010 1534800911	1717 South University Drive	FARGO	ND	Active
DSH350011GW	Child	DSH	SANFORD MEDICAL CENTER FARGO	SANFORD HEARING CENTER - HEARING CENTER 1200.57015	3223 32nd Ave S, Suite 200	FARGO	ND	Active
DSH350011GX	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford Medical Center Fargo / Home Dialysis Bemidji 1200.43010 1500100511 - Sanford Medical Center Fargo / Home Dialysis Bemidji 1200.43010 1500100511	1300 Anne Street Northwest	Bemidji	MN	Active
DSH350011GY	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford Medical Center Fargo / Home Dialysis Detroit Lakes 1200.43015 1500100512 - Sanford Medical Center Fargo / Home Dialysis Detroit Lakes 1200.43015 1500100512	1234 Washington Ave Suite B	Detroit Lakes	MN	Active
DSH350011GZ	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford Medical Center Fargo / Home Dialysis Fargo 1200.42115 1500100501 - Sanford Medical Center Fargo / Home Dialysis Fargo 1200.42115 1500100501	2801 South University Drive	Fargo	ND	Active
DSH350011H	Child	DSH	SANFORD MEDICAL CENTER FARGO	SANFORD SOUTHPOINTE CLINIC / Sanford Southpointe OB/GYN PBB	2400 32ND AVE S	FARGO	ND	Active
DSH350011HA	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford Dialysis Red Lake 1200.42295 1500100505 - Sanford Dialysis Red Lake 1200.42295 1500100505	24760 Hospital Drive	Red Lake	MN	Active
DSH350011HB	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford Dialysis Thief River Falls 1200.42310 1500100506 - Sanford Dialysis Thief River Falls 1200.42310 1500100506	120 Labree Avenue South	Thief River Falls	MN	Active
DSH350011HC	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford Medical Center Fargo/ Home Dialysis Thief River Falls 1200.43013 1500100514 - Sanford Medical Center Fargo/ Home Dialysis Thief River Falls 1200.43013 1500100514	120 Labree Avenue South	Thief River Falls	MN	Active
DSH350011HD	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford Children's Endocrinology and Primary Care 1200.54055 1567801200 - Sanford Children's Endocrinology and Primary Care 1200.54055 1567801200	3955 56th St. S Suite D	Fargo	ND	Active
DSH350011HE	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford Dialysis Morris 1200.42291 1500100504 - Sanford Dialysis Morris 1200.42291 1500100504	400 First Street East	Morris	MN	Active
DSH350011HF	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford Dialysis Bemidji 1200.42265 1500100502 - Sanford Dialysis Bemidji 1200.42265 1500100502	1300 Anne Street Northwest	Bemidji	MN	Active
DSH350011HG	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford Dialysis Detroit Lakes 1200.42280 1500100503 - Sanford Dialysis Detroit Lakes 1200.42280 1500100503	1234 Washington Ave Suite B	Detroit Lakes	MN	Active
DSH350011HH	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford Dialysis Fargo 1200.42100 1500100500 - Sanford Dialysis Fargo 1200.42100 1500100500	2801 South University Drive	Fargo	ND	Active
DSH350011HJ	Child	DSH	SANFORD MEDICAL CENTER FARGO	Women's Multidisciplinary Medicine 55260 1567401300 - Women's Multidisciplinary Medicine 55260 1567401300	2400 32nd Ave South	Fargo	ND	Active
DSH350011HK	Child	DSH	SANFORD MEDICAL CENTER FARGO	CLINICAL NUTRITION PEDS SC 57010 1534800918 - CLINICAL NUTRITION PEDS SC 57010 1534800918	3955 56th St. S Suite D	Fargo	ND	Active
DSH350011HL	Child	DSH	SANFORD MEDICAL CENTER FARGO	Oral Surgery-PBB 55020 - Oral Surgery-PBB 55020	5225 23rd Ave South	Fargo	ND	Active
DSH350011HM	Child	DSH	SANFORD MEDICAL CENTER FARGO	Special Care OP Infusions 42240 1500102201 - Special Care OP Infusions 42240 1500102201	321 8th Ave North	Fargo	ND	Active
DSH350011HN	Child	DSH	SANFORD MEDICAL CENTER FARGO	Gastroenterology-PBB 54005 1530802601 - Gastroenterology-PBB 54005 1530802601	321 8th Ave North	Fargo	ND	Active
DSH350011HP	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford Medical Center Fargo/ Sanford Otolaryngology-PBB - Sanford Medical Center Fargo/ Sanford Otolaryngology-PBB	5225 23rd Ave South	Fargo	ND	Active
DSH350011HQ	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford Medical Center Fargo/ Sanford Nephrology-PBB - Sanford Medical Center Fargo/ Sanford Nephrology-PBB	5225 23rd Ave South	Fargo	ND	Active
DSH350011HR	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford Roger Maris Cancer Center/Sanford Peds Rheumatologist - Sanford Roger Maris Cancer Center/Sanford Peds Rheumatologist	820 4th St N	Fargo	ND	Terminated
DSH350011HS	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford Medical Center Fargo/ Sanford South University Internal Medicine-PBB - Sanford Medical Center Fargo/ Sanford South University Internal Medicine-PBB	1720 University Drive S	Fargo	ND	Terminated
DSH350011HT	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford Medical Center Fargo/ Sanford Infectious Disease/Tc-PBB - Sanford Medical Center Fargo/ Sanford Infectious Disease/Tc-PBB	5225 23rd Ave South	Fargo	ND	Active
DSH350011HU	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford Roger Maris Cancer Center/Sanford Peds Infectious Disease-PBB - Sanford Roger Maris Cancer Center/Sanford Peds Infectious Disease-PBB	820 4th St N	Fargo	ND	Terminated
DSH350011HV	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford Medical Center Fargo /Sanford Peds Infectious Disease-PBB	3955 56th St. S Suite D	Fargo	ND	Active
DSH350011HW	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford Medical Center Fargo/ Sanford Neurosurgery-PBB - Sanford Medical Center Fargo/ Sanford Neurosurgery-PBB	5225 23rd Ave South	Fargo	ND	Active
DSH350011HX	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford Medical Center Fargo/ Sanford Neonatology-PBB - Sanford Medical Center Fargo/ Sanford Neonatology-PBB	5225 23rd Ave South	Fargo	ND	Active
DSH350011HY	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford Medical Center Fargo/Sanford Peds Rheumology-PBB	3955 56th St. S Suite D	Fargo	ND	Active
DSH350011HZ	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford Medical Center Fargo/Medical Genetics-PBB	3955 56th St. S Suite D	Fargo	ND	Active
DSH350011J	Child	DSH	SANFORD MEDICAL CENTER FARGO	SANFORD SOUTH UNIVERSITY / Sanford South University Foot & Ankle Clinic PBB	1720 South University Drive	FARGO	ND	Active
DSH350011JA	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford Medical Center Broadway/Pediatric Neuro-PBB - Sanford Medical Center Broadway/Pediatric Neuro-PBB	3955 S 56TH ST Ste D	Fargo	ND	Active
DSH350011JB	Child	DSH	SANFORD MEDICAL CENTER FARGO	SANFORD FGO PEDS WOUND I94 SC - FGO PEDS WOUND I94 SC	5225 S 23RD AVE	Fargo	ND	Active
DSH350011JC	Child	DSH	SANFORD MEDICAL CENTER FARGO	SANFORD CV DIAG MOORHEAD SC - CV DIAG MOORHEAD SC	4000 S 28TH AVE	Moorhead	MN	Active
DSH350011JD	Child	DSH	SANFORD MEDICAL CENTER FARGO	SANFORD CV DIAG SOUTHWEST SC - CV DIAG SOUTHWEST SC	2701 13TH AVE S	Fargo	ND	Active
DSH350011JE	Child	DSH	SANFORD MEDICAL CENTER FARGO	SANFORD CV DIAG URGNT CARE SU - CV DIAG URGNT CARE SU	1720 S UNIVERSITY DR	Fargo	ND	Active
DSH350011JF	Child	DSH	SANFORD MEDICAL CENTER FARGO	SANFORD CV DIAG WEST FGO SC - CV DIAG WEST FGO SC	1220 SHEYENNE ST	West Fargo	ND	Active
DSH350011JG	Child	DSH	SANFORD MEDICAL CENTER FARGO	SANFORD FGO CV DIAG NEURO25 SC - FGO CV DIAG NEURO25 SC	2301 25TH ST S	Fargo	ND	Terminated
DSH350011JH	Child	DSH	SANFORD MEDICAL CENTER FARGO	SANFORD FARGO PEDIATRIC NEPHROLOGY VETERANS SQUARE CLINIC - FGO PED NEPH VETSQ SC	3955 S 56TH ST Ste D	Fargo	ND	Active
DSH350011JJ	Child	DSH	SANFORD MEDICAL CENTER FARGO	SANFORD FARGO PEDIATRICS SPECIALTY VETERANS SQUARE CLINIC - FGO PED SPEC VETSQ SC	3955 S 56TH ST Ste D	Fargo	ND	Active
DSH350011JK	Child	DSH	SANFORD MEDICAL CENTER FARGO	SANFORD FGO WOUND I94 SC - FGO WOUND I94 SC	5225 S 23RD AVE	Fargo	ND	Terminated
DSH350011JL	Child	DSH	SANFORD MEDICAL CENTER FARGO	SANFORD HOSPICE FARGO - HOSPICE FARGO	820 4th St North	Fargo	ND	Terminated
DSH350011JM	Child	DSH	SANFORD MEDICAL CENTER FARGO	SANFORD FARGO CARDIOVASCULAR DIOGNOSTICS NORTH CLINIC - CV DIAG NO FGO SC	2601 BROADWAY N	Fargo	ND	Active
DSH350011JN	Child	DSH	SANFORD MEDICAL CENTER FARGO	SANFORD CARDIOVASCULAR DIAGNOSTICS SOUTHPOINTE CLINIC - CV DIAG SOUTHPOINTE SC	2400 32ND AVE S	Fargo	ND	Active
DSH350011JP	Child	DSH	SANFORD MEDICAL CENTER FARGO	SANFORD FARGO CARDIOVASCULAR DIAGNOSTICS VETERANS SQUARE CLINIC - CV DIAG VET SQU FGO SC	3955 S 56TH ST Ste D	Fargo	ND	Active
DSH350011JQ	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford OP Hand Procedures-SU - OP Hand Procedures-SU	1720 South University Drive	Fargo	ND	Active
DSH350011JR	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford Radiology-PBB-Veterans - Radiology-PBB-Veterans	3955 S 56TH ST STE D	Fargo	ND	Terminated
DSH350011JS	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford Peds Sleep Lab-Fgo - Peds Sleep Lab-Fgo	2801 S UNIVERSITY DR	Fargo	ND	Active
DSH350011JT	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford Peds OP Dialysis - Peds OP Dialysis	5225 S 23RD AVE	Fargo	ND	Active
DSH350011JU	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford Virtual Preventive Care-PBB-SP - Virtual Preventive Care-PBB-SP	2400 32nd Ave S	Fargo	ND	Active
DSH350011JV	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford Traumatic Stress Treatment Ctr - Traumatic Stress Treatment Ctr	100 4TH ST STE 200	Fargo	ND	Active
DSH350011JW	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford Peds Behavioral Development-PBB - Peds Behavioral Development-PBB	3955 S 56TH ST STE D	Fargo	ND	Active
DSH350011JX	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford Hand Therapy - SU - Hand Therapy - SU	1720 South University Drive	Fargo	ND	Active
DSH350011JY	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford Fargo CTC - SU - Fargo CTC - SU	1717 South University Drive	Fargo	ND	Active
DSH350011JZ	Child	DSH	SANFORD MEDICAL CENTER FARGO	Jamestown 2 Radiology Dept - Jamestown 2 Radiology Dept	300 2ND AVE NE	Jamestown	ND	Active
DSH350011K	Child	DSH	SANFORD MEDICAL CENTER FARGO	SANFORD SOUTHPOINTE CLINIC / Sanford Southpointe Allergy PBB	2400 32ND AVE S	FARGO	ND	Active
DSH350011KA	Child	DSH	SANFORD MEDICAL CENTER FARGO	Jamestown Physical Therapy Dept - Jamestown Physical Therapy Dept	904 5TH AVE NE	Jamestown	ND	Active
DSH350011KB	Child	DSH	SANFORD MEDICAL CENTER FARGO	Wahpeton CV Diag Dept - Wahpeton CV Diag Dept	332 2ND AVE N	Wahpeton	ND	Active
DSH350011KC	Child	DSH	SANFORD MEDICAL CENTER FARGO	Valley City Internal Med Dept - Valley City Internal Med Dept	520 CHAUTAUQUA BLVD	Valley City	ND	Active
DSH350011KD	Child	DSH	SANFORD MEDICAL CENTER FARGO	Jamestown 2 Family Med Dept - Jamestown 2 Family Med Dept	300 2ND AVE NE	Jamestown	ND	Active
DSH350011KE	Child	DSH	SANFORD MEDICAL CENTER FARGO	SU Radiology Ultrasound SU SC - SU Radiology Ultrasound SU SC	1720 S UNIVERSITY DR	Fargo	ND	Active
DSH350011KF	Child	DSH	SANFORD MEDICAL CENTER FARGO	Jamestown Surgery Dept - Jamestown Surgery Dept	300 2ND AVE NE	Jamestown	ND	Active
DSH350011KG	Child	DSH	SANFORD MEDICAL CENTER FARGO	Valley City Family Med Dept - Valley City Family Med Dept	520 CHAUTAUQUA BLVD	Valley City	ND	Active
DSH350011KH	Child	DSH	SANFORD MEDICAL CENTER FARGO	Jamestown Family Med Dept - Jamestown Family Med Dept	904 5TH AVE NE	Jamestown	ND	Active
DSH350011KJ	Child	DSH	SANFORD MEDICAL CENTER FARGO	Stress Lab Wahpeton Dept - Stress Lab Wahpeton Dept	332 2ND AVE N	Wahpeton	ND	Active
DSH350011KK	Child	DSH	SANFORD MEDICAL CENTER FARGO	Wahpeton Radiology Dept - Wahpeton Radiology Dept	332 2ND AVE N	Wahpeton	ND	Active
DSH350011KL	Child	DSH	SANFORD MEDICAL CENTER FARGO	Jamestown Chiropractic Dept - Jamestown Chiropractic Dept	904 5TH AVE NE	Jamestown	ND	Active
DSH350011KM	Child	DSH	SANFORD MEDICAL CENTER FARGO	Wahpeton Family Med Dept - Wahpeton Family Med Dept	332 2ND AVE N	Wahpeton	ND	Active
DSH350011KN	Child	DSH	SANFORD MEDICAL CENTER FARGO	Valley City Behavioral Health - Valley City Behavioral Health	520 CHAUTAUQUA BLVD	Valley City	ND	Active
DSH350011KP	Child	DSH	SANFORD MEDICAL CENTER FARGO	Devils Lake Physical Therapy - Devils Lake Physical Therapy	618 14TH AVE NE	Devils Lake	ND	Active
DSH350011KQ	Child	DSH	SANFORD MEDICAL CENTER FARGO	Grand Forks Behavioral Health Dept - Grand Forks Behavioral Health Dept	1750 47TH AVE S	Grand Forks	ND	Active
DSH350011KR	Child	DSH	SANFORD MEDICAL CENTER FARGO	Grand Forks Walk In Dept - Grand Forks Walk In Dept	1750 47TH AVE S	Grand Forks	ND	Active
DSH350011KS	Child	DSH	SANFORD MEDICAL CENTER FARGO	Grand Forks Radiology Dept - Grand Forks Radiology Dept	1750 47TH AVE S	Grand Forks	ND	Active
DSH350011KT	Child	DSH	SANFORD MEDICAL CENTER FARGO	Grand Forks MRI Dept - Grand Forks MRI Dept	1750 47TH AVE S	Grand Forks	ND	Active
DSH350011KU	Child	DSH	SANFORD MEDICAL CENTER FARGO	Grand Forks Diab Educ Dept - Grand Forks Diab Educ Dept	1750 47TH AVE S	Grand Forks	ND	Active
DSH350011KV	Child	DSH	SANFORD MEDICAL CENTER FARGO	Grand Forks CV Diag Dept - Grand Forks CV Diag Dept	1750 47TH AVE S	Grand Forks	ND	Active
DSH350011KW	Child	DSH	SANFORD MEDICAL CENTER FARGO	Wahpeton Behavioral Health Dept - Wahpeton Behavioral Health Dept	332 2ND AVE N	Wahpeton	ND	Active
DSH350011KX	Child	DSH	SANFORD MEDICAL CENTER FARGO	Devils Lake CV Diag Dept - Devils Lake CV Diag Dept	618 14TH AVE NE	Devils Lake	ND	Active
DSH350011KY	Child	DSH	SANFORD MEDICAL CENTER FARGO	Wahpeton Internal Med Dept - Wahpeton Internal Med Dept	332 2ND AVE N	Wahpeton	ND	Active
DSH350011KZ	Child	DSH	SANFORD MEDICAL CENTER FARGO	Grand Forks Family Med Dept - Grand Forks Family Med Dept	1750 47TH AVE S	Grand Forks	ND	Active
DSH350011L	Child	DSH	SANFORD MEDICAL CENTER FARGO	SANFORD SOUTHPOINTE CLINIC / Sanford Southpointe Rheumatology PBB	2400 32ND AVE S	FARGO	ND	Active
DSH350011LA	Child	DSH	SANFORD MEDICAL CENTER FARGO	Wahpeton Surgery Dept - Wahpeton Surgery Dept	332 2ND AVE N	Wahpeton	ND	Active
DSH350011LB	Child	DSH	SANFORD MEDICAL CENTER FARGO	Grand Forks Clin Nut Dept - Grand Forks Clin Nut Dept	1750 47TH AVE S	Grand Forks	ND	Active
DSH350011LC	Child	DSH	SANFORD MEDICAL CENTER FARGO	Jamestown 2 CV Diag Dept - Jamestown 2 CV Diag Dept	300 2ND AVE NE	Jamestown	ND	Active
DSH350011LD	Child	DSH	SANFORD MEDICAL CENTER FARGO	Jamestown Audiology Dept - Jamestown Audiology Dept	904 5TH AVE NE	Jamestown	ND	Active
DSH350011LE	Child	DSH	SANFORD MEDICAL CENTER FARGO	Wahpeton Physical Therapy Dept - Wahpeton Physical Therapy Dept	123 Second Ave N	Wahpeton	ND	Active
DSH350011LF	Child	DSH	SANFORD MEDICAL CENTER FARGO	Valley City Psychology Dept - Valley City Psychology Dept	520 CHAUTAUQUA BLVD	Valley City	ND	Active
DSH350011LG	Child	DSH	SANFORD MEDICAL CENTER FARGO	Grand Forks Internal Med Dept - Grand Forks Internal Med Dept	1750 47TH AVE S	Grand Forks	ND	Active
DSH350011LH	Child	DSH	SANFORD MEDICAL CENTER FARGO	Wahpeton Optometry - Wahpeton Optometry	332 2ND AVE N	Wahpeton	ND	Active
DSH350011LJ	Child	DSH	SANFORD MEDICAL CENTER FARGO	Devils Lake Radiology Dept - Devils Lake Radiology Dept	618 14TH AVE NE	Devils Lake	ND	Active
DSH350011LK	Child	DSH	SANFORD MEDICAL CENTER FARGO	SANFORD MEDICAL CENTER FARGO - Jamestown Radiology Dept	904 5TH AVE NE	JAMESTOWN	ND	Active
DSH350011LL	Child	DSH	SANFORD MEDICAL CENTER FARGO	Devils Lake Family Med Dept - Devils Lake Family Med Dept	618 14TH AVE NE	Devils Lake	ND	Active
DSH350011LM	Child	DSH	SANFORD MEDICAL CENTER FARGO	Valley City Radiology Dept - Valley City Radiology Dept	520 CHAUTAUQUA BLVD	Valley City	ND	Active
DSH350011LN	Child	DSH	SANFORD MEDICAL CENTER FARGO	Wahpeton Occupational Therapy Dept - Wahpeton Occupational Therapy Dept	123 Second Ave N	Wahpeton	ND	Active
DSH350011LP	Child	DSH	SANFORD MEDICAL CENTER FARGO	Jamestown 2 Psychology Dept - Jamestown 2 Psychology Dept	300 2ND AVE NE	Jamestown	ND	Active
DSH350011LQ	Child	DSH	SANFORD MEDICAL CENTER FARGO	Jamestown Occupational Therapy Dept - Jamestown Occupational Therapy Dept	904 5TH AVE NE	Jamestown	ND	Active
DSH350011LR	Child	DSH	SANFORD MEDICAL CENTER FARGO	Medical Genetics RMCC Dept - Medical Genetics RMCC Dept	820 N 4TH ST	Fargo	ND	Active
DSH350011LS	Child	DSH	SANFORD MEDICAL CENTER FARGO	BDWY Internal Med_PBB Dept - BDWY Internal Med_PBB Dept	737 BROADWAY N	Fargo	ND	Active
DSH350011LT	Child	DSH	SANFORD MEDICAL CENTER FARGO	Medical Oncology Wahpeton Dept - Medical Oncology Wahpeton Dept	332 2ND AVE N	Wahpeton	ND	Active
DSH350011LU	Child	DSH	SANFORD MEDICAL CENTER FARGO	Chiropratic Services - Chiropratic Services	2301 25TH ST S	Fargo	ND	Active
DSH350011LV	Child	DSH	SANFORD MEDICAL CENTER FARGO	Spine Clinic Chiropractic Deptartment - Spine Clinic Chiropractic Deptartment	2301 25TH ST S	Fargo	ND	Active
DSH350011LW	Child	DSH	SANFORD MEDICAL CENTER FARGO	Horace Family Med - Horace Family Med	7951 JACKS WAY	Horace	ND	Active
DSH350011LX	Child	DSH	SANFORD MEDICAL CENTER FARGO	Moorhead Peds Endocrinology - Moorhead Peds Endocrinology	4000 S 28TH AVE	Moorhead	MN	Active
DSH350011LY	Child	DSH	SANFORD MEDICAL CENTER FARGO	Dermatology Jamestown Dept - Dermatology Jamestown Dept	904 5TH AVE NE	Jamestown	ND	Active
DSH350011LZ	Child	DSH	SANFORD MEDICAL CENTER FARGO	Child Psychology Moorhead Dept - Child Psychology Moorhead Dept	4000 S 28TH AVE	Moorhead	MN	Active
DSH350011M	Child	DSH	SANFORD MEDICAL CENTER FARGO	SANFORD SOUTHPOINTE CLINIC / Sanford Southpointe Endocrinology PBB	2400 32ND AVE S	FARGO	ND	Active
DSH350011MA	Child	DSH	SANFORD MEDICAL CENTER FARGO	Peds Orthopedics SU Dept - Peds Orthopedics SU Dept	1720 S UNIVERSITY DR	Fargo	ND	Active
DSH350011MB	Child	DSH	SANFORD MEDICAL CENTER FARGO	Hand Surgery Grand Forks Dept - Hand Surgery Grand Forks Dept	3035 DEMERS AVE	Grand Forks	ND	Active
DSH350011MC	Child	DSH	SANFORD MEDICAL CENTER FARGO	Peds Neph Dept - Peds Neph Dept	2701 13TH AVE S	Fargo	ND	Active
DSH350011MD	Child	DSH	SANFORD MEDICAL CENTER FARGO	Neuro Grand Forks Dept - Neuro Grand Forks Dept	1750 47TH AVE S	Grand Forks	ND	Active
DSH350011ME	Child	DSH	SANFORD MEDICAL CENTER FARGO	SMCF Speech Pathology Dept - SMCF Speech Pathology Dept	5225 S 23RD AVE	Fargo	ND	Active
DSH350011MF	Child	DSH	SANFORD MEDICAL CENTER FARGO	Occupational Therapy SMCF - Occupational Therapy SMCF	5225 S 23RD AVE	Fargo	ND	Active
DSH350011MG	Child	DSH	SANFORD MEDICAL CENTER FARGO	SU Psych OT Dept - SU Psych OT Dept	1720 S UNIVERSITY DR	Fargo	ND	Active
DSH350011MH	Child	DSH	SANFORD MEDICAL CENTER FARGO	Physical Therapy SMCF - Physical Therapy SMCF	5225 S 23RD AVE	Fargo	ND	Active
DSH350011MJ	Child	DSH	SANFORD MEDICAL CENTER FARGO	Orthopedic PT OSM Dept - Orthopedic PT OSM Dept	2301 25TH ST S STE A	Fargo	ND	Active
DSH350011MK	Child	DSH	SANFORD MEDICAL CENTER FARGO	Medical Fitness Cardiac Rehab Dept - Medical Fitness Cardiac Rehab Dept	5225 S 23RD AVE	Fargo	ND	Active
DSH350011ML	Child	DSH	SANFORD MEDICAL CENTER FARGO	Disease Management - Disease Management	5225 S 23RD AVE	Fargo	ND	Active
DSH350011MM	Child	DSH	SANFORD MEDICAL CENTER FARGO	Respiratory Care Dept SU - Respiratory Care Dept SU	1720 S UNIVERSITY DR	Fargo	ND	Active
DSH350011MN	Child	DSH	SANFORD MEDICAL CENTER FARGO	Peds Physical Therapy - Physical Therapy	2400 32ND AVE S	Fargo	ND	Active
DSH350011N	Child	DSH	SANFORD MEDICAL CENTER FARGO	SANFORD SOUTHPOINTE CLINIC / Sanford Southpointe Eye Services PBB	2400 32ND AVE S	FARGO	ND	Active
DSH350011P	Child	DSH	SANFORD MEDICAL CENTER FARGO	SANFORD SOUTHPOINTE CLINIC / Sanford Chiropractic Services PBB	2400 32ND AVE S	FARGO	ND	Terminated
DSH350011Q	Child	DSH	SANFORD MEDICAL CENTER FARGO	SANFORD SOUTHPOINTE CLINIC / Sanford Southpointe Internal Medicine PBB	2400 32ND AVE S	FARGO	ND	Active
DSH350011R	Child	DSH	SANFORD MEDICAL CENTER FARGO	SANFORD SOUTHPOINTE CLINIC / Sanford Southpointe Family Medicine PBB	2400 32ND AVE S	FARGO	ND	Active
DSH350011S	Child	DSH	SANFORD MEDICAL CENTER FARGO	SANFORD SOUTHPOINTE CLINIC / Sanford Spine Rehabilitation	2400 32ND AVE S	FARGO	ND	Active
DSH350011T	Child	DSH	SANFORD MEDICAL CENTER FARGO	SANFORD SOUTHPOINTE CLINIC / Sanford Cardiac Rehab	2400 32ND AVE S	FARGO	ND	Active
DSH350011U	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford Medical Center Fargo / Sanford Radiology MRI	5225 23rd Ave S	FARGO	ND	Active
DSH350011V	Child	DSH	SANFORD MEDICAL CENTER FARGO	SANFORD SOUTHPOINTE CLINIC / Sanford Pulmonary Rehab	2400 32ND AVE S	FARGO	ND	Terminated
DSH350011W	Child	DSH	SANFORD MEDICAL CENTER FARGO	SANFORD SOUTHPOINTE CLINIC / Sanford Respiratory Therapy	2400 32ND AVE S	FARGO	ND	Terminated
DSH350011X	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford South University Urgent Care / Sanford Radiology South University PBB	1720 S UNIVERSITY DR	FARGO	ND	Active
DSH350011Y	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford Medical Center Fargo / Sanford South University Anesthesiology PBB	1720 South University Drive	Fargo	ND	Active
DSH350011Z	Child	DSH	SANFORD MEDICAL CENTER FARGO	Sanford Medical Center Fargo / Sanford South University Radiology Diagnostic	1720 South University Drive	Fargo	ND	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Addresses	Shipping Address	Insert	Group Change Request		Sanford Medical Center Fargo 801 Broadway N Fargo, ND 58102	12/17/2024 7:27 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1124122783	12/17/2024 7:27 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		MN	12/17/2024 7:27 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1235173519	12/17/2024 7:27 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		MN	12/17/2024 7:27 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1295374288	12/17/2024 7:27 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		MN	12/17/2024 7:27 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1568789121	12/17/2024 7:27 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		MN	12/17/2024 7:27 AM
Details	Last Recertification Date	Update	Recertification	8/30/2023 2:37:07 PM	9/5/2024 9:24:26 AM	9/5/2024 9:24 AM
Contacts	Authorizing Official	Update	AO Change Request	Lawrence, Tiffany President and CEO, Fargo Sanford Medical Center Fargo 7014172314	Herrmann, Kristin Vice President, Finance Sanford Medical Center Fargo 7014172326	1/30/2024 7:27 AM
Contacts	Authorizing Official	Update	Change Request	Herrmann, Kristin Vice President, Finance Sanford Medical Center Fargo 7014172326	Lawrence, Tiffany President and CEO, Fargo Sanford Medical Center Fargo 7014172314	10/24/2023 8:27 AM
Contacts	Signed By	Update	Change Request	Lawrence, Tiffany Vice President Finance Sanford Medical Center Fargo 7014172326	Lawrence, Tiffany President and CEO, Fargo Sanford Medical Center Fargo 7014172314	10/20/2023 12:34 PM
Details	Last Recertification Date	Update	Recertification	9/12/2022 11:27:44 AM	8/30/2023 2:37:07 PM	8/30/2023 2:37 PM
Contacts	Authorizing Official	Update	Change Request	Lawrence, Tiffany Vice President Finance Sanford Medical Center Fargo 7014172326	Herrmann, Kristin Vice President, Finance Sanford Medical Center Fargo 7014172326	2/1/2023 7:16 AM
Contacts	Primary Contact	Update	Profile Change Request	Breidenbach, Jesse System Executive Director, Pharmacy Sanford Medical Center Fargo 7012346887	Breidenbach, Jesse Vice President, Pharmacy Sanford Health 7012346887	1/9/2023 6:20 AM
Contacts	Primary Contact	Update	Recertification	Leedahl, Nathan Manager, Pharmacy Sanford Medical Center Fargo 7014172310	Breidenbach, Jesse System Executive Director, Pharmacy Sanford Medical Center Fargo 7012346887	9/12/2022 11:27 AM
Details	Last Recertification Date	Update	Recertification	8/19/2021 9:07:39 AM	9/12/2022 11:27:44 AM	9/12/2022 11:27 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/12/2021 3:47 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1861927709	11/12/2021 3:47 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		MN	11/12/2021 3:47 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/12/2021 3:47 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1558458844	11/12/2021 3:47 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		MN	11/12/2021 3:47 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1861927709	11/12/2021 3:47 PM
Medicaid Billing	NPI: State	Insert	Change Request		MN	11/12/2021 3:47 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1558458844	11/12/2021 3:47 PM
Medicaid Billing	NPI: State	Insert	Change Request		MN	11/12/2021 3:47 PM
Details	Last Recertification Date	Update	Recertification	8/21/2020 2:14:01 PM	8/19/2021 9:07:39 AM	8/19/2021 9:07 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/13/2020 10:03 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1457315	12/13/2020 10:03 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		ND	12/13/2020 10:03 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/13/2020 10:03 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1528009412	12/13/2020 10:03 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		MN	12/13/2020 10:03 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1528009412	12/13/2020 10:03 AM
Medicaid Billing	NPI: State	Insert	Change Request		ND	12/13/2020 10:03 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1528009412	12/13/2020 10:03 AM
Medicaid Billing	NPI: State	Insert	Change Request		MN	12/13/2020 10:03 AM
Details	Last Recertification Date	Update	Recertification	9/3/2019 10:41:07 AM	8/21/2020 2:14:01 PM	8/21/2020 2:14 PM
Contacts	Primary Contact	Update	Profile Change Request	Leedahl, Nathan Lead Pharmacist Sanford Medical Center Fargo 7014172310	Leedahl, Nathan Manager, Pharmacy Sanford Medical Center Fargo 7014172310	1/10/2020 3:29 PM
Details	Last Recertification Date	Update	Recertification	8/21/2018 10:24:17 AM	9/3/2019 10:41:07 AM	9/3/2019 10:41 AM
Details	Entity Name	Update	Recertification	SANFORD MEDICAL CENTER - FARGO	SANFORD MEDICAL CENTER FARGO	9/3/2019 10:40 AM
Contacts	Primary Contact	Update	Change Request	Breidenbach, Jesse Senior Director, Enterprise Pharmacy Sanford Medical Center Fargo 7014172307	Leedahl, Nathan Lead Pharmacist Sanford Medical Center Fargo 7014172310	4/2/2019 10:32 AM
Contacts	Authorizing Official	Update	Profile Change Request	Lawrence, Tiffany Vice President Finance Sanford Medical Center Fargo 7012346449	Lawrence, Tiffany Vice President Finance Sanford Medical Center Fargo 7014172326	8/21/2018 3:17 PM
Contacts	Signed By	Update	Profile Change Request	Lawrence, Tiffany Vice President Finance Sanford Medical Center Fargo 7012346449	Lawrence, Tiffany Vice President Finance Sanford Medical Center Fargo 7014172326	8/21/2018 3:17 PM
Contacts	Primary Contact	Update	Profile Change Request	Breidenbach, Jesse Enterprise Director, Enterprise Pharmacy Sanford Medical Center Fargo 7014172307	Breidenbach, Jesse Senior Director, Enterprise Pharmacy Sanford Medical Center Fargo 7014172307	8/21/2018 10:36 AM
Details	Last Recertification Date	Update	Recertification	11/4/2017 3:31:41 PM	8/21/2018 10:24:17 AM	8/21/2018 10:24 AM
Contacts	Primary Contact	Update	Recertification	Breidenbach, Jesse Senior Director, Enterprise Pharmacy Sanford Medical Center Fargo 7014172307	Breidenbach, Jesse Enterprise Director, Enterprise Pharmacy Sanford Medical Center Fargo 7014172307	8/21/2018 10:22 AM
Contacts	Primary Contact	Update	Profile Change Request	Breidenbach, Jesse Enterprise Director, Enterprise Pharmacy Sanford Medical Center Fargo 7014172307	Breidenbach, Jesse Senior Director, Enterprise Pharmacy Sanford Medical Center Fargo 7014172307	8/21/2018 10:20 AM
Contacts	Primary Contact	Update	Contract Pharmacy Change Request	Breidenbach, Jesse Director of Pharmacy Sanford Medical Center Fargo 7014172307	Breidenbach, Jesse Enterprise Director, Enterprise Pharmacy Sanford Medical Center Fargo 7014172307	8/21/2018 10:18 AM
Contacts	Primary Contact	Update	Contract Pharmacy Change Request	Breidenbach, Jesse Enterprise Director, Enterprise Pharmacy Sanford Medical Center Fargo 7014172307	Breidenbach, Jesse Director of Pharmacy Sanford Medical Center Fargo 7014172307	8/21/2018 10:17 AM
Contacts	Primary Contact	Update	Contract Pharmacy Change Request	Breidenbach, Jesse Director of Pharmacy Sanford Medical Center Fargo 7014172307	Breidenbach, Jesse Enterprise Director, Enterprise Pharmacy Sanford Medical Center Fargo 7014172307	8/21/2018 10:17 AM
Contacts	Primary Contact	Update	Contract Pharmacy Change Request	Breidenbach, Jesse Enterprise Director, Enterprise Pharmacy Sanford Medical Center Fargo 7014172307	Breidenbach, Jesse Director of Pharmacy Sanford Medical Center Fargo 7014172307	8/21/2018 10:17 AM
Contacts	Primary Contact	Update	Profile Change Request	Breidenbach, Jesse Director of Pharmacy Sanford Medical Center Fargo 7014172307	Breidenbach, Jesse Enterprise Director, Enterprise Pharmacy Sanford Medical Center Fargo 7014172307	8/21/2018 9:55 AM
Details	Last Recertification Date	Update	Recertification	10/26/2017 1:14:14 PM	11/4/2017 3:31:41 PM	11/4/2017 3:31 PM
Details	Last Recertification Date	Update	Recertification		10/26/2017 1:14:14 PM	10/26/2017 1:14 PM
Contacts	Authorizing Official	Update		Lawrence, Tiffany Vice President Finance 7012346449	Lawrence, Tiffany Vice President Finance Sanford Medical Center Fargo 7012346449	9/26/2017 9:20 AM
Contacts	Signed By	Update		Lawrence, Tiffany Vice President Finance 7012346449	Lawrence, Tiffany Vice President Finance Sanford Medical Center Fargo 7012346449	9/26/2017 9:20 AM
Contacts	Primary Contact	Update	Profile Change Request	Breidenbach, Jesse Director of Pharmacy Sanford Medical Center Fargo 7012345616	Breidenbach, Jesse Director of Pharmacy Sanford Medical Center Fargo 7014172307	9/20/2017 4:38 PM
Contacts	Primary Contact	Update		Breidenbach, Jesse Director of Pharmacy 7012345616	Breidenbach, Jesse Director of Pharmacy Sanford Medical Center Fargo 7012345616	9/19/2017 12:15 PM
Contacts	Primary Contact	Insert			Breidenbach, Jesse Director of Pharmacy 7012345616	8/1/2017 9:23 AM
Contacts	Authorizing Official	Insert			Lawrence, Tiffany Vice President Finance 7012346449	8/1/2017 9:23 AM
Contacts	Signed By	Insert			Lawrence, Tiffany Vice President Finance 7012346449	8/1/2017 9:23 AM
Addresses	Main Address	Insert			1720 South University Drive Fargo, ND 58103	7/25/2017 1:38 PM
Dates	Participating Approval Date	Update			3/3/2017 12:00:00 AM	3/3/2017 11:28 AM
Details	State	Update		Pending	Active	3/3/2017 11:28 AM
Dates	Start Date	Update			4/1/2017 12:00:00 AM	3/3/2017 11:28 AM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_74057	DSH350011AC	1/31/2017 10:20 AM
Details	340B ID	Update			OUTPATIENT_ONLINE_REG_74057	1/5/2017 5:03 PM
Details	Last Recertification Date	Insert				1/5/2017 5:03 PM
Details	Grant Number	Insert				1/5/2017 5:03 PM
Details	340B ID	Insert				1/5/2017 5:03 PM
Details	Is Authorizing Official EHB Data	Insert				1/5/2017 5:03 PM
Dates	Last Date That 340B Drugs Purchased	Insert				1/5/2017 5:03 PM
Details	Medicare Provider Number	Insert			350011	1/5/2017 5:03 PM
Details	Entity Name	Insert			SANFORD MEDICAL CENTER - FARGO	1/5/2017 5:03 PM
Details	Program Code	Insert			DSH	1/5/2017 5:03 PM
Details	Entity Subname	Insert			Sanford Medical Center Fargo / Sanford South University Speech Therapy	1/5/2017 5:03 PM
Dates	Participating Approval Date	Insert				1/5/2017 5:03 PM
Details	State	Insert			Pending	1/5/2017 5:03 PM
Dates	Registration Date	Insert			1/5/2017 12:00:00 AM	1/5/2017 5:03 PM
Dates	Signed By Date	Insert			1/5/2017 12:00:00 AM	1/5/2017 5:03 PM
Dates	Start Date	Insert				1/5/2017 5:03 PM
Terminations	Termination Comments	Insert				1/5/2017 5:03 PM
Terminations	Termination Date	Insert				1/5/2017 5:03 PM
Terminations	Termination Effective Date	Insert				1/5/2017 5:03 PM
Terminations	Termination Reason	Insert				1/5/2017 5:03 PM