Healthcare Provider Details

I. General information

NPI: 1245317304
Provider Name (Legal Business Name): KEVIN L SHADY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 03/12/2024
Certification Date: 03/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

915 N GRAND BLVD
SAINT LOUIS MO
63106-1621
US

IV. Provider business mailing address

915 N GRAND BLVD
SAINT LOUIS MO
63106-1621
US

V. Phone/Fax

Practice location:
  • Phone: 314-652-4100
  • Fax:
Mailing address:
  • Phone: 314-652-4100
  • Fax: 314-548-4748

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number036088119
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: