Provider Demographics
NPI:1730146457
Name:SHEA, KEVIN S (MD)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:S
Last Name:SHEA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2492 E RIVER RD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85718-9552
Mailing Address - Country:US
Mailing Address - Phone:520-722-8994
Mailing Address - Fax:520-624-0117
Practice Address - Street 1:2492 E RIVER RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85718-9552
Practice Address - Country:US
Practice Address - Phone:520-335-6849
Practice Address - Fax:520-459-2191
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2021-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1973632085R0202X
AZ161432085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00142429OtherRR MEDICARE
040901000017OtherFIDELIS
NY1973635WOtherWORKERS COMPENSATION
P010197363OtherBLUE CHOICE
00026123303OtherUNIVERA
0142867OtherGHI
NY01970314Medicaid
197255FFOtherPREFERRED CARE
000525458004OtherBLUE SHIELD WNY
5610364OtherINDEPENDENT HEALTH
P00140112OtherRR MEDICARE
P020197363OtherBLUE SHIELD ROCHESTER
00026123305OtherUNIVERA
000525458006OtherBLUE SHIELD WNY
4194144OtherGHI
AZ471306Medicaid
RB2814Medicare PIN
5610364OtherINDEPENDENT HEALTH
197255FFOtherPREFERRED CARE