1801875869 NPI number — KEVIN J BARDWELL MD

Table of content: KEVIN J BARDWELL MD (NPI 1801875869)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801875869 NPI number — KEVIN J BARDWELL MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BARDWELL
Provider First Name:
KEVIN
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1801875869
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1702 UNIVERSITY DR S
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FARGO
Provider Business Mailing Address State Name:
ND
Provider Business Mailing Address Postal Code:
58103-4940
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13060 ISLE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BAXTER
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56425-8331
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-828-2880
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/10/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  36003 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0572149 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 41084933956001C072 . This is a "CHAMPUS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 62B41BA . This is a "BCBS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 0118449 . This is a "MEDICA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 21851 . This is a "AMERICAS PPO" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 32013500 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 204283500 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 105085 . This is a "UCARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: NA2951006282 . This is a "PREFERRED ONE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 080163236 . This is a "RR MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: HP15832 . This is a "HEALTH PARTNERS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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