NPIMap

Individual provider Active NPI

Kenneth Cushing Botelho, PA-C

  • Physician Assistant
  • East Providence, RI
National Provider Identifier
1184977514
Registry record updated May 16, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Physician AssistantTaxonomy code 363A00000X
License
PA00716 Issued in RI
Practice address
450 Veterans Memorial Pkwy BLDG 9
East Providence, RI 02914-5300
Phone
(401) 435-5533
Fax
(401) 435-3586
NPI assigned
Oct 23, 2012
Last updated
May 16, 2025By the provider in NPPES
Sex
Male
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on May 16, 2025

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Physician Assistant 363A00000X 15285 MN
Physician Assistant 363A00000X PA00716 RI Primary

Addresses

Primary practice location

450 Veterans Memorial Pkwy BLDG 9
East Providence, RI 02914-5300

Mailing address

450 Veterans Memorial Pkwy BLDG 9
East Providence, RI 02914-5300
Phone (401) 435-5533

Other practice location 1

4855 W Arrowhead Rd
Hermantown, MN 55811-3936
Phone (218) 786-3540

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MN
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20250523000221 MN Practitioner - Physician Assistant 6901030766 Reassigns benefits to 4 organizations

Care Compare profile

Medicare Care Compare
Specialty
Physician Assistant
Education
Other, 2012
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices
The Duluth Clinic LTDGroup PAC ID 2567374283, 1,135 clinicians

Practice addresses (Care Compare)

1502 London Rd
Suite 102
Duluth, MN 55812-1787
Phone (218) 727-8228

Hospital & facility affiliations

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Physician Assistant

Practice roles

OrganizationSpecialtyStatusNew patients
The Duluth Clinic, LTD Current Accepting new patients
The Duluth Clinic, LTD. CurrentSince Jun 30, 2025 Accepting new patients
The Duluth Clinic, LTD Current Accepting new patients
Essentia Health Moose Lake CurrentSince Nov 20, 2025 Accepting new patients
The Duluth Clinic, LTD CurrentSince Jun 30, 2025 Accepting new patients
Pine Medical Center CurrentSince Sep 15, 2025 Accepting new patients
The Duluth Clinic LTD Current Accepting new patients
Moose Lake Community Hospital District Current Accepting new patients
Essentia Health Virginia LLC Past Accepting new patients

Locations

1502 London Rd
Ste 102
Duluth, MN 55812
Phone (218) 576-0100

400 E 3rd St
Duluth, MN 55805
Phone (218) 722-8364

4212 Grand Ave
Duluth, MN 55807
Phone (218) 786-3500

4621 E Superior St
Duluth, MN 55804
Phone (218) 786-3550

4855 W Arrowhead Rd
Hermantown, MN 55811
Phone (218) 786-3540

4572 County Road 61
Moose Lake, MN 55767
Phone (218) 485-4481

211 S Boundary Ave
Proctor, MN 55810
Phone (218) 624-4818

705 Lundorff Dr
Sandstone, MN 55072
Phone (320) 245-2211

Organizations & group practices 11

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

Hospital & facility affiliations 4

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1350950400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1747353600000",
    "number": "1184977514",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "450 VETERANS MEMORIAL PKWY BLDG 9",
            "city": "EAST PROVIDENCE",
            "state": "RI",
            "postal_code": "029145300",
            "telephone_number": "401-435-5533",
            "fax_number": "401-435-3586"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "450 VETERANS MEMORIAL PKWY BLDG 9",
            "city": "EAST PROVIDENCE",
            "state": "RI",
            "postal_code": "029145300",
            "telephone_number": "401-435-5533",
            "fax_number": "401-435-3586"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "4855 W Arrowhead Rd",
            "address_purpose": "LOCATION",
            "city": "Hermantown",
            "state": "MN",
            "postal_code": "558113936",
            "country_code": "US",
            "telephone_number": "218-786-3540",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "BOTELHO",
        "first_name": "KENNETH",
        "middle_name": "CUSHING",
        "credential": "PA-C",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2012-10-23",
        "last_updated": "2025-05-16",
        "certification_date": "2025-05-16",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "MN",
            "license": "15285",
            "primary": false
        },
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "RI",
            "license": "PA00716",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in East Providence, RI

Sources for this page

Verify at the official NPI Registry.