Provider Demographics
NPI:1750318283
Name:SHANAGHAN, KEVIN JOHN (DO)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:JOHN
Last Name:SHANAGHAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:1341 S ELISEO DR STE 200
Mailing Address - Street 2:
Mailing Address - City:GREENBRAE
Mailing Address - State:CA
Mailing Address - Zip Code:94904-2000
Mailing Address - Country:US
Mailing Address - Phone:415-464-8169
Mailing Address - Fax:415-925-9712
Practice Address - Street 1:1341 S ELISEO DR STE 200
Practice Address - Street 2:
Practice Address - City:GREENBRAE
Practice Address - State:CA
Practice Address - Zip Code:94904-2000
Practice Address - Country:US
Practice Address - Phone:415-464-8169
Practice Address - Fax:415-925-9712
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2022-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS007370E207Q00000X
MEDO2758207Q00000X
CA20A18062207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001264101Medicaid
PA0527142000OtherAMERIHEALTH 65 PA
PAP004726OtherGATEWAY-WMG
PA140375OtherUNISON-WMG HERR'S RIDGE
PA146180OtherUNISON-WMG THURMONT
PA20026342OtherAH MERCY-WMG THURMONT
PA50021844OtherCAPITAL BC-WMG THURMONT
PA692270OtherHIGHMARK BLUE SHIELD
PA7429OtherGEISINGER
PA219458OtherMAMSI-WMG
MD403896Medicaid
PA50080314OtherCAPITAL BC-WMG-ST.CHARLES
PA5122170OtherAETNA
PA080187668OtherRAILROAD MEDICARE
MD616924OtherCAREFIRST MD BCBS
PA104877OtherJOHNS HOPKINS
PA50018543OtherCAPITAL BC-WMG HERR'S RID
PA20020665OtherAH MERCY-WMG HERR'S RIDGE
PAP004726OtherGATEWAY-WMG
PA001264101Medicaid
PA146180OtherUNISON-WMG THURMONT
PA219458OtherMAMSI-WMG
PA692270EZ3Medicare PIN