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General NPI Number Information
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NPI Number | 1801854039
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Entity Type | Individual
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Provider Name | KENNETH F SHOCKLEY D.O.
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Gender | Male
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Dates
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Enumeration Date | 05/04/2006
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Last Update Date | 02/18/2026
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Provider Practice Location Address
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Address Line | 4047 E HILLS CT SE
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City | GRAND RAPIDS
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State | MI
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Zip | 49546-6249
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Country | US
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Telephone | 616-956-9577
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Fax | 616-956-5988
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Provider Business Mailing Address
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Address Line | 20952 E 12 MILE RD STE 200
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City | SAINT CLAIR SHORES
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State | MI
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Zip | 48081-3203
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Country | US
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Telephone | 586-771-4820
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208800000X
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Taxonomy Name | Urology Physician
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License Number | 5101010606
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License Number State | MI
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