Individual
SHANE W KENNEDY
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
2221 8TH AVE, FORT WORTH, TX 76110-1812
(817) 336-5060
(817) 336-1744
Mailing address
2221 8TH AVE, FORT WORTH, TX 76110-1812
(817) 336-5060
(817) 336-1744
Taxonomy
Speciality
Code
Description
License number
State
207RN0300X
Nephrology Physician
Primary
L6086
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
10012357
AMERIGROUP
—
05
—
158632301
—
TX
01
—
1634611
UNISYS
—
01
—
7724474
AETNA
—
01
—
8J5430
BCBS OF TX
TX
01
—
P00040101
MEDICARE RAILROAD
—
Enumeration date
06/15/2006
Last updated
03/18/2021
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