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DSH350011GK SANFORD MEDICAL CENTER FARGO (Active)
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Main Details
Name
SANFORD MEDICAL CENTER FARGO
Subdivision Name
PEDIATRIC NEPHROLOGY WEST FARGO CLINIC - PEDIATRIC NEPHROLOGY 1200.53075
Type
Disproportionate Share Hospital
Rural
Yes
340B ID
DSH350011GK
Medicare Provider Number
350011
Outpatient Facility Provider Number
Additional Details
Current Program Status
Active
Registration Date
4/29/2021
Participating Start Date
5/12/2021
Participating Approval Date
5/6/2021
Last Recertification Date
8/28/2024
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
1220 Sheyenne St
WEST FARGO, ND 58078
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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Participated starting 7/1/2020, terminated 7/1/2020. Reinstated 5/12/2021.
05/12/2021
April 2025
April 2025
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