MEDICARE: SHELBY A. KENNER MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	01061016A	IN

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	P00405718	OTHER	IN	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000000519082	OTHER		BLUE CROSS BLUE SHIELD
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1538170832
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHELBY A. KENNER MD

Provider Business Mailing Address
First Line	:	6920 POINTE INVERNESS WAY STE 200
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46804-7934
Country	:	US
Telephone Number	:	260-458-3210
Fax Number	:	260-458-3211

Provider Business Practice Location Address
First Line	:	5717 S ANTHONY BLVD
Second Line	:	SUITE 100
City	:	FORT WAYNE
State	:	IN
Zip	:	46806-3386
Country	:	US
Telephone Number	:	260-469-3984
Fax Number	:	260-441-3375

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/11/2006
Last Update Date	:	08/15/2022

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Directions to “ SHELBY A. KENNER MD” Practice Location

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