Provider Demographics
NPI:1700854023
Name:SHEWELL, KENNETH W (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:W
Last Name:SHEWELL
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:PO BOX 8657
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MO
Mailing Address - Zip Code:64508-8657
Mailing Address - Country:US
Mailing Address - Phone:816-866-5105
Mailing Address - Fax:816-207-0454
Practice Address - Street 1:2600 MILLER ST
Practice Address - Street 2:
Practice Address - City:BETHANY
Practice Address - State:MO
Practice Address - Zip Code:64424-2701
Practice Address - Country:US
Practice Address - Phone:660-425-0253
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-11
Last Update Date:2023-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO112862208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO208865105Medicaid
020037751OtherRAILROAD MEDICARE
MO208865105Medicaid
F93798Medicare UPIN