Provider Demographics
NPI:1114928199
Name:SHAHEEN, KENNETH W (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:W
Last Name:SHAHEEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-02
Last Update Date:2010-07-07
Deactivation Date:2006-03-21
Deactivation Code:
Reactivation Date:2006-03-27
Provider Licenses
StateLicense IDTaxonomies
MI2086S0122X174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2761424Medicaid
MI0631714Medicare ID - Type Unspecified
MI2761424Medicaid