Individual
DR. SHANNON KENNEDY
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
MD
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
Primary
249109
SC
208000000X
Pediatrics Physician
24910
SC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
249109
—
SC
01
—
5551
MEDICARE GROUP #
SC
01
—
GP4841
MEDICAID GROUP #
SC
01
—
P00700010
RAILROAD MC ID-PRIOR 5/1/09
SC
Enumeration date
07/10/2006
Last updated
02/27/2013
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