Basic Information
| Provider Information | |||||||||
| NPI: | 1639270069 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WENTWORTH | ||||||||
| FirstName: | KEVIN | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 415 JEFFERSON ST NORTH | ||||||||
| Address2: | TRI-COUNTY HEALTH CARE | ||||||||
| City: | WADENA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 564821296 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2186313510 | ||||||||
| FaxNumber: | 2186317507 | ||||||||
| Practice Location | |||||||||
| Address1: | 1027 WASHINGTON AVENUE | ||||||||
| Address2: | |||||||||
| City: | DETROIT LAKES | ||||||||
| State: | MN | ||||||||
| PostalCode: | 565013409 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2188475611 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2006 | ||||||||
| LastUpdateDate: | 09/11/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 44499 | MN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 274948 | 05 | OR | MEDICAID | HP42348 | 01 | MN | HEALTHPARTNERS | OTHER | 074M7WE | 01 | MN | BCBS | OTHER | 1031036 | 01 | MN | PREFERREDONE | OTHER | 01-14159 | 01 | MN | MEDICA | OTHER | 41091744413 | 05 | NE | MEDICAID | 82362200 | 05 | WI | MEDICAID | 11772 | 05 | ND | MEDICAID | 256961200 | 05 | MN | MEDICAID | 169526 | 01 | MN | UCAREMN | OTHER |