Provider Demographics
NPI:1235174376
Name:WRIGHT, KENNETH JAMES (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:JAMES
Last Name:WRIGHT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2401 DEMERS AVE
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201
Mailing Address - Country:US
Mailing Address - Phone:701-780-1891
Mailing Address - Fax:318-254-2229
Practice Address - Street 1:711 DELMORE DR - ALTRU CLINIC/ROSEAU
Practice Address - Street 2:
Practice Address - City:ROSEAU
Practice Address - State:MN
Practice Address - Zip Code:56751-1534
Practice Address - Country:US
Practice Address - Phone:218-463-1365
Practice Address - Fax:218-463-3928
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2019-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.15640R207Q00000X
ARE3349207Q00000X
MN46906207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5F528OtherBCBS-MEDICAL PARK DRS GP
AR146792001Medicaid
AR160354002Medicaid
AR5M277OtherBCBS
LA1460818Medicaid
AR160354002Medicaid
AR160354002Medicaid
LA$$$$$$$$$BOtherLA-BCBS
AR5M277OtherBCBS
DE5852Medicare ID - Type UnspecifiedMEDICAL PARK DRS GRP#
AR5M277Medicare ID - Type UnspecifiedINDIVIDUAL NUMBER