Healthcare Provider Details

I. General information

NPI: 1700854023
Provider Name (Legal Business Name): KENNETH W SHEWELL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/11/2006
Last Update Date: 01/04/2023
Certification Date: 01/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 MILLER ST
BETHANY MO
64424-2701
US

IV. Provider business mailing address

PO BOX 8657
SAINT JOSEPH MO
64508-8657
US

V. Phone/Fax

Practice location:
  • Phone: 660-425-0253
  • Fax:
Mailing address:
  • Phone: 816-866-5105
  • Fax: 816-207-0454

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number112862
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: