NPIMap

Individual provider Active NPI

Kenji Sudoh

  • Sports Medicine (Family Medicine) Physician
  • Duluth, MN
National Provider Identifier
1619996832
Registry record updated May 9, 2011
On this page

Key facts

NPPES NPI Registry
Primary specialty
Sports Medicine (Family Medicine) PhysicianTaxonomy code 207QS0010X
License
45872 Issued in MN
Practice address
400 E 3Rd St
Duluth, MN 55805-1951
Phone
(218) 786-8364
NPI assigned
Jul 19, 2006
Sex
Male
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on May 9, 2011

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

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Sports Medicine (Family Medicine) Physician 207QS0010X 45872 MN Primary

Addresses

Primary practice location

400 E 3Rd St
Duluth, MN 55805-1951

Mailing address

400 E 3Rd St
Duluth, MN 55805-1951

Other identifiers 1

IdentifierTypeStateIssuer
532492100MedicaidMN

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
I20031217000429 MN Practitioner - Sports MedicinePractitioner - Family Practice 5294632329 Reassigns benefits to 3 organizations

Care Compare profile

Medicare Care Compare
Specialty
Family Practice
Education
University of Minnesota Medical School, 2002
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Telehealth
Offers telehealth services
Group practices
Advantage Physical Therapy and Sports Rehab, LLCGroup PAC ID 8022016336, shared by 3 NPIs, 289 clinicians
Polinsky Medical Rehabilitation CenterGroup PAC ID 0941377360, 369 clinicians
The Duluth Clinic LTDGroup PAC ID 2567374283, 1,135 clinicians

Practice addresses (Care Compare)

112 Ash St
Spooner, WI 54801-1487
Phone (715) 635-3979

1600 Miller Trunk Hwy
Duluth, MN 55811-5640
Phone (218) 786-5360

Hospital & facility affiliations

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Doctor of Medicine

Practice roles

OrganizationSpecialtyStatusNew patients
Deer River Healthcare Center, Inc. CurrentSince Jul 1, 2013 Accepting new patients
The Duluth Clinic LTD CurrentSince Mar 1, 2017 Accepting new patients
Deer River Healthcare Center, Inc. CurrentSince Jul 1, 2013 Accepting new patients
The Duluth Clinic LTD Current Accepting new patients
The Duluth Clinic, LTD Past Accepting new patients
Deer River Healthcare Center, Inc Past Accepting new patients

Locations

115 10th Ave NE
Deer River, MN 56636
Phone (218) 246-2900

115 10th Ave NE
#A
Deer River, MN 56636
Phone (218) 246-8275

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

1600 Miller Trunk Hwy
Ste 1300
Duluth, MN 55811
Phone (218) 786-3392

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

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

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

Organizations & group practices 7

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

Hospital & facility affiliations 11

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": "1153267200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1304899200000",
    "number": "1619996832",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "400 E 3RD ST",
            "city": "DULUTH",
            "state": "MN",
            "postal_code": "558051951"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "400 E 3RD ST",
            "city": "DULUTH",
            "state": "MN",
            "postal_code": "558051951",
            "telephone_number": "218-786-8364"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "SUDOH",
        "first_name": "KENJI",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2006-07-19",
        "last_updated": "2011-05-09",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207QS0010X",
            "taxonomy_group": "",
            "desc": "Family Medicine, Sports Medicine",
            "state": "MN",
            "license": "45872",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "532492100",
            "state": "MN"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Duluth, MN

Sources for this page

Verify at the official NPI Registry.