MEDICARE: KENDRA SHIRLEY MATHEWS

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	208100000X	Physical Medicine & Rehabilitation Physician	5502000566	MI

General Provider Information

NPI Number	:	1699400457
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KENDRA SHIRLEY MATHEWS

Provider Business Mailing Address
First Line	:	5235 WHIPPLE LAKE RD
Second Line	:
City	:	CLARKSTON
State	:	MI
Zip	:	48348-3054
Country	:	US
Telephone Number	:	248-390-9553
Fax Number	:

Provider Business Practice Location Address
First Line	:	10770 ELIZABETH LAKE RD
Second Line	:
City	:	WHITE LAKE
State	:	MI
Zip	:	48386-2136
Country	:	US
Telephone Number	:	248-618-4100
Fax Number	:

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

Provider Enumeration Date	:	07/17/2022
Last Update Date	:	07/17/2022

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Directions to “ KENDRA SHIRLEY MATHEWS ” Practice Location

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