Basic Information
| Provider Information | |||||||||
| NPI: | 1407110265 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KENNEDY | ||||||||
| FirstName: | SHAUN | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 800 EAST 28TH ST MR 11112 | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6128636590 | ||||||||
| FaxNumber: | 6128635247 | ||||||||
| Practice Location | |||||||||
| Address1: | 1575 BEAM AVE | ||||||||
| Address2: | |||||||||
| City: | MAPLEWOOD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551092502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6512327348 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2012 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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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 | 390200000X | MN | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207P00000X | 59164 | MN | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.