Healthcare Provider Details

I. General information

NPI: 1407110265
Provider Name (Legal Business Name): SHAUN KENNEDY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2012
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1575 BEAM AVE
MAPLEWOOD MN
55109-2502
US

IV. Provider business mailing address

800 EAST 28TH ST MR 11112
MINNEAPOLIS MN
55407
US

V. Phone/Fax

Practice location:
  • Phone: 651-232-7348
  • Fax:
Mailing address:
  • Phone: 612-863-6590
  • Fax: 612-863-5247

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number59164
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: