NPIMap

Individual provider Active NPI

Shane Byrn Richardson, M.D.

  • Family Medicine Physician
  • Cloquet, MN
National Provider Identifier
1659710374
Registry record updated Jan 29, 2019
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
License
64730 Issued in MN
Practice address
927 Trettel LN
Cloquet, MN 55720-1345
Phone
(218) 879-1227
NPI assigned
Jun 15, 2013
Sex
Male
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Jan 29, 2019

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

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine Physician 207Q00000X R73957 AZ
Family Medicine Physician 207Q00000X 64730 MN Primary

Addresses

Primary practice location

927 Trettel LN
Cloquet, MN 55720-1345

Mailing address

1105 101St Ave W
Duluth, MN 55808-1804
Phone (612) 251-8798

Other practice location 1

707 N Alvernon Way
Ste 101
Tucson, AZ 85711-1827
Phone (520) 694-1614

Other practice location 2

221 W 4th St
Duluth, MN 55806-2719
Phone (218) 879-1227

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
I20181120000528 MN Practitioner - Family Practice 4981987807 Reassigns benefits to 2 organizations

Care Compare profile

Medicare Care Compare
Specialty
Family Practice
Education
Other, 2011
Medicare assignment
May accept Medicare assignment
Group practices

Practice addresses (Care Compare)

211 W 4TH St
Duluth, MN 55806-2719
Phone (218) 879-1227

Hospital & facility affiliations

Procedures performed for Medicare patients

ProcedureNumber of procedures
Removal of nail tissue1-10

National Provider Directory

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

State licenses

LicenseStateTypeSpecialty
R73957AZMDFamily Medicine Physician

Practice roles

OrganizationSpecialtyStatusNew patients
Community Memorial Hospital Association CurrentSince Oct 6, 2018 Accepting new patients
Fond Du Lac Reservation Business Committee CurrentSince Nov 1, 2018 Accepting new patients
Fond Du Lac Reservation Business Committee CurrentSince Nov 1, 2018 Accepting new patients
St. Luke'S Hospital of Duluth Past Accepting new patients

Locations

927 Trettel Ln
Cloquet, MN 55720
Phone (218) 879-1227

512 Skyline Blvd
Cloquet, MN 55720
Phone (218) 878-7207

211 W 4th St
Duluth, MN 55806
Phone (218) 726-1370

221 W 4th St
Duluth, MN 55806
Phone (218) 279-4142

Interoperability endpoints

  • Direct secure messaging: shane.richardson.p1@direct.fonddulachsd.nextgenshare.com

Organizations & group practices 4

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 26

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

View all 26

NPI Registry JSON

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

{
    "created_epoch": "1371254400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1548720000000",
    "number": "1659710374",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1105 101ST AVE W",
            "city": "DULUTH",
            "state": "MN",
            "postal_code": "558081804",
            "telephone_number": "612-251-8798"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "927 TRETTEL LN",
            "city": "CLOQUET",
            "state": "MN",
            "postal_code": "557201345",
            "telephone_number": "218-879-1227"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "707 N Alvernon Way",
            "address_2": "Ste 101",
            "address_purpose": "LOCATION",
            "city": "Tucson",
            "state": "AZ",
            "postal_code": "857111827",
            "country_code": "US",
            "telephone_number": "520-694-1614",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "221 W 4th St",
            "address_purpose": "LOCATION",
            "city": "Duluth",
            "state": "MN",
            "postal_code": "558062719",
            "country_code": "US",
            "telephone_number": "218-879-1227",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "RICHARDSON",
        "first_name": "SHANE",
        "middle_name": "BYRN",
        "name_prefix": "Dr.",
        "credential": "M.D.",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2013-06-15",
        "last_updated": "2019-01-29",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "AZ",
            "license": "R73957",
            "primary": false
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "MN",
            "license": "64730",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Cloquet, MN

Sources for this page

Verify at the official NPI Registry.