Basic Information
| Provider Information | |||||||||
| NPI: | 1245317304 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHADY | ||||||||
| FirstName: | KEVIN | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 55 WESTPORT PLAZA DRIVE | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | ST LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 63146 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3145484772 | ||||||||
| FaxNumber: | 3145484748 | ||||||||
| Practice Location | |||||||||
| Address1: | ONE MEMORIAL DRIVE | ||||||||
| Address2: | ALTON MEMORIAL HOSPITAL | ||||||||
| City: | ALTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 62002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6184637415 | ||||||||
| FaxNumber: | 3148212180 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2006 | ||||||||
| LastUpdateDate: | 04/09/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 036088119 | IL | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 300066968 | 01 | RR CARE | OTHER | 300066978 | 01 | RR CARE | OTHER | 0360881191 | 05 | IL | MEDICAID | 46068 | 01 | HCARE USA | OTHER | 208893503 | 05 | MO | MEDICAID | 0006021895 | 01 | IL | BLUE | OTHER | 1609006 | 01 | PH PLAN | OTHER | 431725842MID | 01 | MERCY | OTHER | 300066973 | 01 | RR CARE | OTHER | 398004 | 01 | HLT PART | OTHER | 18177 | 01 | BLUER CHOICE | OTHER | 2781 | 01 | GHP | OTHER | 1390 | 01 | MO | BLUE | OTHER | 251709 | 01 | H LINK | OTHER | F70866 | 01 | GATE WAY | OTHER |