Provider Demographics
NPI:1225035694
Name:SHEA, KEVIN P (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:P
Last Name:SHEA
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:UCONN MEDICAL GROUP
Mailing Address - Street 2:263 FARMINGTON AVE
Mailing Address - City:FARMINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06030-0001
Mailing Address - Country:US
Mailing Address - Phone:860-679-6600
Mailing Address - Fax:860-679-6649
Practice Address - Street 1:UCONN MEDICAL GROUP
Practice Address - Street 2:263 FARMINGTON AVE
Practice Address - City:FARMINGTON
Practice Address - State:CT
Practice Address - Zip Code:06030-0001
Practice Address - Country:US
Practice Address - Phone:860-679-6600
Practice Address - Fax:860-679-6649
Is Sole Proprietor?:No
Enumeration Date:2005-06-30
Last Update Date:2022-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT029051207XX0005X, 207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1290519Medicaid
CT1290519Medicaid
CT200000383Medicare PIN