Basic Information
| Provider Information | |||||||||
| NPI: | 1801875869 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BARDWELL | ||||||||
| FirstName: | KEVIN | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1702 UNIVERSITY DR S | ||||||||
| Address2: | |||||||||
| City: | FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 581034940 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 13060 ISLE DR | ||||||||
| Address2: | |||||||||
| City: | BAXTER | ||||||||
| State: | MN | ||||||||
| PostalCode: | 564258331 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2188282880 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/10/2006 | ||||||||
| LastUpdateDate: | 07/08/2019 | ||||||||
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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 | 36003 | MN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0572149 | 05 | IA | MEDICAID | 41084933956001C072 | 01 | CHAMPUS | OTHER | 62B41BA | 01 | MN | BCBS | OTHER | 0118449 | 01 | MN | MEDICA | OTHER | 21851 | 01 | MN | AMERICAS PPO | OTHER | 32013500 | 05 | WI | MEDICAID | 204283500 | 05 | MN | MEDICAID | 105085 | 01 | MN | UCARE | OTHER | NA2951006282 | 01 | MN | PREFERRED ONE | OTHER | 080163236 | 01 | RR MEDICARE | OTHER | HP15832 | 01 | MN | HEALTH PARTNERS | OTHER |