Healthcare Provider Details

I. General information

NPI: 1427092238
Provider Name (Legal Business Name): WILLIAM KENNETH HUTCHISON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2006
Last Update Date: 03/29/2022
Certification Date: 03/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2701 13TH AVE S
FARGO ND
58103-3602
US

IV. Provider business mailing address

2701 13TH AVE S
FARGO ND
58103-3602
US

V. Phone/Fax

Practice location:
  • Phone: 701-234-3600
  • Fax: 701-234-3515
Mailing address:
  • Phone: 701-234-3600
  • Fax: 701-234-3515

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number01059605A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number10772
License Number StateND

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier200341780
Identifier TypeMEDICAID
Identifier StateIN
Identifier Issuer
# 2
Identifier14490
Identifier TypeMEDICAID
Identifier StateND
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: