Provider Demographics
NPI:1801875869
Name:BARDWELL, KEVIN J (MD)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:J
Last Name:BARDWELL
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 1:1702 UNIVERSITY DR S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-4940
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13060 ISLE DR
Practice Address - Street 2:
Practice Address - City:BAXTER
Practice Address - State:MN
Practice Address - Zip Code:56425-8331
Practice Address - Country:US
Practice Address - Phone:218-828-2880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-10
Last Update Date:2019-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN36003207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0572149Medicaid
41084933956001C072OtherCHAMPUS
MN62B41BAOtherBCBS
MN0118449OtherMEDICA
MN21851OtherAMERICAS PPO
WI32013500Medicaid
MN204283500Medicaid
MN105085OtherUCARE
MNNA2951006282OtherPREFERRED ONE
080163236OtherRR MEDICARE
MNHP15832OtherHEALTH PARTNERS
IA0572149Medicaid
MN21851OtherAMERICAS PPO