Healthcare Provider Details

I. General information

NPI: 1093987927
Provider Name (Legal Business Name): KENNETH W. SHAHEEN, M.D.,P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/01/2008
Last Update Date: 04/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2585 CROOKS RD
TROY MI
48084-4702
US

IV. Provider business mailing address

2585 CROOKS RD
TROY MI
48084-4702
US

V. Phone/Fax

Practice location:
  • Phone: 248-283-1110
  • Fax: 248-283-1114
Mailing address:
  • Phone: 248-283-1110
  • Fax: 248-283-1114

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberKS048031
License Number StateMI

VIII. Authorized Official

Name: MRS. MICHELLE MARIE PORTER
Title or Position: MEDICAL BILLER
Credential:
Phone: 248-283-1110