Provider Demographics
NPI:1821022302
Name:KENNEDY, SHANNON (MD)
Entity type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 WAPPOO CREEK DR
Mailing Address - Street 2:2A
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29412-2135
Mailing Address - Country:US
Mailing Address - Phone:843-737-5206
Mailing Address - Fax:843-795-7171
Practice Address - Street 1:109 WAPPOO CREEK DR
Practice Address - Street 2:2A
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29412-2135
Practice Address - Country:US
Practice Address - Phone:843-737-5206
Practice Address - Fax:843-795-7171
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2013-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC24910208000000X
SC249109207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC249109Medicaid
SCGP4841OtherMEDICAID GROUP #
SCP00700010OtherRAILROAD MC ID-PRIOR 5/1/09
SC5551OtherMEDICARE GROUP #
SC249109Medicaid