Healthcare Provider Details

I. General information

NPI: 1114928199
Provider Name (Legal Business Name): KENNETH W SHAHEEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/02/2005
Last Update Date: 07/07/2010
Certification Date:
Deactivation Date: 03/21/2006
Reactivation Date: 03/27/2006

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 Number2086S0122X
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: