Provider Demographics
NPI:1538170832
Name:KENNER, SHELBY A (MD)
Entity type:Individual
Prefix:
First Name:SHELBY
Middle Name:A
Last Name:KENNER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SHELBY
Other - Middle Name:A
Other - Last Name:DIETRICH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6920 POINTE INVERNESS WAY STE 200
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-7934
Mailing Address - Country:US
Mailing Address - Phone:260-458-3210
Mailing Address - Fax:260-458-3211
Practice Address - Street 1:5717 S ANTHONY BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46806-3386
Practice Address - Country:US
Practice Address - Phone:260-469-3984
Practice Address - Fax:260-441-3375
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2022-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01061016A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000519082OtherBLUE CROSS BLUE SHIELD
IN200531880Medicaid
INP00405718OtherRAILROAD MEDICARE
IN200531880Medicaid
INM400048049Medicare PIN
INI36209Medicare UPIN
IN200531880Medicaid