Provider Demographics
NPI:1679517569
Name:KENNEDY, SHANE W (MD)
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:W
Last Name:KENNEDY
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 1:2221 8TH AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76110-1812
Mailing Address - Country:US
Mailing Address - Phone:817-336-5060
Mailing Address - Fax:817-336-1744
Practice Address - Street 1:2221 8TH AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76110-1812
Practice Address - Country:US
Practice Address - Phone:817-336-5060
Practice Address - Fax:817-336-1744
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2021-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL6086207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX158632301Medicaid
P00040101OtherMEDICARE RAILROAD
10012357OtherAMERIGROUP
1634611OtherUNISYS
TX8J5430OtherBCBS OF TX
7724474OtherAETNA
TX8J5430OtherBCBS OF TX
P00040101OtherMEDICARE RAILROAD
TX158632301Medicaid