Provider Demographics
NPI:1245317304
Name:SHADY, KEVIN L (MD)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:L
Last Name:SHADY
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 1:915 N GRAND BLVD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63106-1621
Mailing Address - Country:US
Mailing Address - Phone:314-652-4100
Mailing Address - Fax:314-548-4748
Practice Address - Street 1:915 N GRAND BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63106-1621
Practice Address - Country:US
Practice Address - Phone:314-652-4100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2024-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360881192085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
300066968OtherRR CARE
300066973OtherRR CARE
MO1390OtherBLUE
MO208893503Medicaid
398004OtherHLT PART
46068OtherHCARE USA
IL0360881191Medicaid
2781OtherGHP
F70866OtherGATE WAY
431725842MIDOtherMERCY
IL0006021895OtherBLUE
18177OtherBLUER CHOICE
1609006OtherPH PLAN
251709OtherH LINK
300066978OtherRR CARE
300066973OtherRR CARE
ILL40190Medicare ID - Type Unspecified
ILL40190Medicare PIN