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DSH350011JK SANFORD MEDICAL CENTER FARGO (Terminated)
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Main Details
Name
SANFORD MEDICAL CENTER FARGO
Subdivision Name
SANFORD FGO WOUND I94 SC - FGO WOUND I94 SC
Type
Disproportionate Share Hospital
Rural
Yes
340B ID
DSH350011JK
Medicare Provider Number
350011
Outpatient Facility Provider Number
Additional Details
Current Program Status
Terminated
Registration Date
7/14/2022
Participating Start Date
10/1/2022
Participating Approval Date
8/19/2022
Last Recertification Date
8/30/2023
Termination Date
Termination Reason
10/1/2024
Other
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
5225 S 23RD AVE
Fargo, ND 58104
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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