MEDICARE: KENNETH F SHOCKLEY D.O.

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	208800000X	Urology Physician	5101010606	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1801854039
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KENNETH F SHOCKLEY D.O.

Provider Business Mailing Address
First Line	:	20952 E 12 MILE RD STE 200
Second Line	:
City	:	SAINT CLAIR SHORES
State	:	MI
Zip	:	48081-3203
Country	:	US
Telephone Number	:	586-771-4820
Fax Number	:

Provider Business Practice Location Address
First Line	:	4047 E HILLS CT SE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49546-6249
Country	:	US
Telephone Number	:	616-956-9577
Fax Number	:	616-956-5988

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

Provider Enumeration Date	:	05/04/2006
Last Update Date	:	02/18/2026

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Directions to “ KENNETH F SHOCKLEY D.O.” Practice Location

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