NPIMap

Individual provider Active NPI

Mark Kenneth Widstrom

  • Obstetrics & Gynecology Physician
  • Duluth, MN
National Provider Identifier
1689692758
Registry record updated May 9, 2011
On this page

Key facts

NPPES NPI Registry
Primary specialty
Obstetrics & Gynecology PhysicianTaxonomy code 207V00000X
License
45497 Issued in MN
Practice address
400 E 3Rd St
Duluth, MN 55805-1951
Phone
(218) 786-8364
NPI assigned
Jul 17, 2006
Last updated
May 9, 2011By the provider in NPPES
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
Obstetrics & Gynecology Physician 207V00000X 45497 MN Primary

Addresses

Primary practice location

400 E 3Rd St
Duluth, MN 55805-1951

Mailing address

400 E 3Rd St
Duluth, MN 55805-1951
Phone (218) 786-8364

Other identifiers 2

IdentifierTypeStateIssuer
34348400MedicaidWI
542440200MedicaidMN

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
I20040210000684 MN Practitioner - Obstetrics/Gynecology 4789578865 Reassigns benefits to 6 organizations

Care Compare profile

Medicare Care Compare
Specialty
Obstetrics/Gynecology
Education
University of Minnesota Medical School, 1993
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices
Polinsky Medical Rehabilitation CenterGroup PAC ID 0941377360, 369 clinicians
The Duluth Clinic LTDGroup PAC ID 2567374283, 1,135 clinicians

Practice addresses (Care Compare)

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

400 E 3Rd St
Duluth, MN 55805-1951
Phone (218) 786-8364

402 E 2ND St
Duluth, MN 55805-1906
Phone (218) 786-4000

420 E 1St St
Duluth, MN 55805-1901
Phone (218) 786-8364

502 E 2ND St
Duluth, MN 55805-1913
Phone (218) 786-8364

530 E 2ND St
Duluth, MN 55805-1913
Phone (218) 786-8364

Hospital & facility affiliations

Procedures performed for Medicare patients

ProcedureNumber of procedures
Removal of the uterus1-10

National Provider Directory

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

Practice roles

OrganizationSpecialtyStatusNew patients
Essentia Health Virginia, LLC CurrentSince Jan 1, 2013 Accepting new patients
Essentia Health Moose Lake CurrentSince Aug 1, 2023 Accepting new patients
Deer River Healthcare Center, Inc. CurrentSince Jul 1, 2013 Accepting new patients
Deer River Healthcare Center, Inc. Current Accepting new patients
The Duluth Clinic, LTD. CurrentSince Dec 1, 2013 Accepting new patients
The Duluth Clinic, LTD CurrentSince Dec 1, 2013 Accepting new patients
Essentia Health Moose Lake CurrentSince Aug 1, 2023 Accepting new patients
Deer River Healthcare Center, Inc CurrentSince Jul 1, 2013 Accepting new patients
The Duluth Clinic LTD Current Accepting new patients
Moose Lake Community Hospital District Current Accepting new patients
Essentia Health Virginia, LLC CurrentSince Jan 1, 2013 Accepting new patients
St Marys Medical Center Past Accepting new patients
The Duluth Clinic, LTD 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

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

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

603 9th St N
Virginia, MN 55792
Phone (218) 741-3013

901 9th St N
Virginia, MN 55792
Phone (218) 741-3340

Organizations & group practices 14

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.

View all 14

Hospital & facility affiliations 7

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": "1153094400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1304899200000",
    "number": "1689692758",
    "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",
            "telephone_number": "218-786-8364"
        },
        {
            "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": "WIDSTROM",
        "first_name": "MARK",
        "middle_name": "KENNETH",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2006-07-17",
        "last_updated": "2011-05-09",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207V00000X",
            "taxonomy_group": "",
            "desc": "Obstetrics & Gynecology",
            "state": "MN",
            "license": "45497",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "34348400",
            "state": "WI"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "542440200",
            "state": "MN"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Duluth, MN

Sources for this page

Verify at the official NPI Registry.