Basic Information
| Provider Information | |||||||||
| NPI: | 1285805952 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHAVER | ||||||||
| FirstName: | KERRY | ||||||||
| MiddleName: | EUGENE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5478 | ||||||||
| Address2: | |||||||||
| City: | THIBODAUX | ||||||||
| State: | LA | ||||||||
| PostalCode: | 703025478 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9407048415 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 604 N ACADIA RD | ||||||||
| Address2: | STE 410 | ||||||||
| City: | THIBODAUX | ||||||||
| State: | LA | ||||||||
| PostalCode: | 70301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9854934004 | ||||||||
| FaxNumber: | 9854934007 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/20/2008 | ||||||||
| LastUpdateDate: | 07/05/2018 | ||||||||
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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 | 207R00000X | 204575 | LA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | P01169638 | 01 | LA | RAILROAD MEDICARE | OTHER | 1500640 | 05 | LA | MEDICAID |