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DSH350011FJ SANFORD MEDICAL CENTER - FARGO (Terminated)
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Main Details
Name
SANFORD MEDICAL CENTER - FARGO
Subdivision Name
Sanford Medical Center Fargo / 5A SMCF
Type
Disproportionate Share Hospital
Rural
Yes
340B ID
DSH350011FJ
Medicare Provider Number
350011
Outpatient Facility Provider Number
Additional Details
Current Program Status
Terminated
Registration Date
1/9/2019
Participating Start Date
4/1/2019
Participating Approval Date
1/10/2019
Last Recertification Date
Termination Date
Termination Reason
10/1/2019
Other
Contacts
Authorizing Official
Sanford Medical Center Fargo
Tiffany Lawrence, President and CEO, Fargo
(701) 417-2314
Primary Contact
Sanford Health
Jesse Breidenbach, Vice President, Pharmacy
(701) 234-6887
Addresses
Street Address
5225 23rd Ave S
Fargo, ND 58104
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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