Healthcare Provider Details

I. General information

NPI: 1861465627
Provider Name (Legal Business Name): SHAYNE S KEDDY D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/10/2006
Last Update Date: 12/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24 SOUTHTOWNE DR
POTOSI MO
63664-5729
US

IV. Provider business mailing address

610 SUMPTER DR
FARMINGTON MO
63640-7749
US

V. Phone/Fax

Practice location:
  • Phone: 573-438-3737
  • Fax:
Mailing address:
  • Phone: 573-747-3365
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number2001016005
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number2001016005
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: