1245317304 NPI number — KEVIN L SHADY MD

Table of content: KEVIN L SHADY MD (NPI 1245317304)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245317304 NPI number — KEVIN L SHADY MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHADY
Provider First Name:
KEVIN
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1245317304
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/12/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
915 N GRAND BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT LOUIS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63106-1621
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-652-4100
Provider Business Mailing Address Fax Number:
314-548-4748

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
915 N GRAND BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAINT LOUIS
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63106-1621
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-652-4100
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X , with the licence number:  036088119 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 300066968 . This is a "RR CARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 300066973 . This is a "RR CARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1390 . This is a "BLUE" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 208893503 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 398004 . This is a "HLT PART" identifier . This identifiers is of the category "OTHER".
  • Identifier: 46068 . This is a "HCARE USA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0360881191 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2781 . This is a "GHP" identifier . This identifiers is of the category "OTHER".
  • Identifier: F70866 . This is a "GATE WAY" identifier . This identifiers is of the category "OTHER".
  • Identifier: 431725842MID . This is a "MERCY" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0006021895 . This is a "BLUE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 18177 . This is a "BLUER CHOICE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1609006 . This is a "PH PLAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 251709 . This is a "H LINK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 300066978 . This is a "RR CARE" identifier . This identifiers is of the category "OTHER".




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