Provider Demographics
NPI:1871513374
Name:SANFORD CLINIC
Entity type:Organization
Organization Name:SANFORD CLINIC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:STEVE
Authorized Official - Middle Name:W
Authorized Official - Last Name:GOETSCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-328-6940
Mailing Address - Street 1:1201 S EUCLID AVE
Mailing Address - Street 2:STE 301
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57105-7700
Mailing Address - Country:US
Mailing Address - Phone:605-328-8240
Mailing Address - Fax:605-328-8241
Practice Address - Street 1:1201 S EUCLID AVE
Practice Address - Street 2:STE 301
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105-7700
Practice Address - Country:US
Practice Address - Phone:605-328-8240
Practice Address - Fax:605-328-8241
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-20
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA2538389Medicaid
SDS8255Medicare PIN