1821022302 NPI number — DR. SHANNON KENNEDY MD

Table of content: DR. SHANNON KENNEDY MD (NPI 1821022302)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821022302 NPI number — DR. SHANNON KENNEDY MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KENNEDY
Provider First Name:
SHANNON
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

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:
1821022302
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/27/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
109 WAPPOO CREEK DR
Provider Second Line Business Mailing Address:
2A
Provider Business Mailing Address City Name:
CHARLESTON
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29412-2135
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
843-737-5206
Provider Business Mailing Address Fax Number:
843-795-7171

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
109 WAPPOO CREEK DR
Provider Second Line Business Practice Location Address:
2A
Provider Business Practice Location Address City Name:
CHARLESTON
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29412-2135
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-737-5206
Provider Business Practice Location Address Fax Number:
843-795-7171
Provider Enumeration Date:
07/10/2006

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: 208000000X , with the licence number:  24910 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: 249109 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 249109 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: GP4841 . This is a "MEDICAID GROUP #" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: P00700010 . This is a "RAILROAD MC ID-PRIOR 5/1/09" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: 5551 . This is a "MEDICARE GROUP #" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".




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