1730146457 NPI number — DR. KEVIN S SHEA MD

Table of content: DR. KEVIN S SHEA MD (NPI 1730146457)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730146457 NPI number — DR. KEVIN S SHEA MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHEA
Provider First Name:
KEVIN
Provider Middle Name:
S
Provider Name Prefix Text:
DR.
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:
1730146457
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/09/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2492 E RIVER RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TUCSON
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85718-9552
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
520-722-8994
Provider Business Mailing Address Fax Number:
520-624-0117

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2492 E RIVER RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TUCSON
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85718-9552
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
520-335-6849
Provider Business Practice Location Address Fax Number:
520-459-2191
Provider Enumeration Date:
04/27/2006

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:  197363 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0202X , with the licence number: 16143 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: P00142429 . This is a "RR MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 040901000017 . This is a "FIDELIS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1973635W . This is a "WORKERS COMPENSATION" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: P010197363 . This is a "BLUE CHOICE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 00026123303 . This is a "UNIVERA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0142867 . This is a "GHI" identifier . This identifiers is of the category "OTHER".
  • Identifier: 01970314 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 197255FF . This is a "PREFERRED CARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 000525458004 . This is a "BLUE SHIELD WNY" identifier . This identifiers is of the category "OTHER".
  • Identifier: 5610364 . This is a "INDEPENDENT HEALTH" identifier . This identifiers is of the category "OTHER".
  • Identifier: P00140112 . This is a "RR MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: P020197363 . This is a "BLUE SHIELD ROCHESTER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 00026123305 . This is a "UNIVERA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 000525458006 . This is a "BLUE SHIELD WNY" identifier . This identifiers is of the category "OTHER".
  • Identifier: 4194144 . This is a "GHI" identifier . This identifiers is of the category "OTHER".
  • Identifier: 471306 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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