Provider Demographics
NPI:1093987927
Name:KENNETH W. SHAHEEN, M.D.,P.C.
Entity Type:Organization
Organization Name:KENNETH W. SHAHEEN, M.D.,P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL BILLER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:PORTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-283-1110
Mailing Address - Street 1:2585 CROOKS RD
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48084-4702
Mailing Address - Country:US
Mailing Address - Phone:248-283-1110
Mailing Address - Fax:248-283-1114
Practice Address - Street 1:2585 CROOKS RD
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48084-4702
Practice Address - Country:US
Practice Address - Phone:248-283-1110
Practice Address - Fax:248-283-1114
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-01
Last Update Date:2008-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIKS048031174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2406317142OtherBCBS OF MICHIGAN
MIE93384Medicare UPIN