=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235174376
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KENNETH JAMES WRIGHT MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/20/2006
-----------------------------------------------------
Last Update Date | 05/01/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 711 DELMORE DR - ALTRU CLINIC/ROSEAU
-----------------------------------------------------
City | ROSEAU
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56751-1534
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 218-463-1365
-----------------------------------------------------
Fax | 218-463-3928
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2401 DEMERS AVE
-----------------------------------------------------
City | GRAND FORKS
-----------------------------------------------------
State | ND
-----------------------------------------------------
Zip | 58201
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 701-780-1891
-----------------------------------------------------
Fax | 318-254-2229
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | MD.15640R
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | E3349
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 46906
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------