Basic Information
| Provider Information | |||||||||
| NPI: | 1730146457 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHEA | ||||||||
| FirstName: | KEVIN | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2492 E RIVER RD | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857189552 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5207228994 | ||||||||
| FaxNumber: | 5206240117 | ||||||||
| Practice Location | |||||||||
| Address1: | 2492 E RIVER RD | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857189552 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5203356849 | ||||||||
| FaxNumber: | 5204592191 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/27/2006 | ||||||||
| LastUpdateDate: | 11/09/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 11/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 197363 | NY | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 16143 | AZ | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | P00142429 | 01 | RR MEDICARE | OTHER | 040901000017 | 01 | FIDELIS | OTHER | 1973635W | 01 | NY | WORKERS COMPENSATION | OTHER | P010197363 | 01 | BLUE CHOICE | OTHER | 00026123303 | 01 | UNIVERA | OTHER | 0142867 | 01 | GHI | OTHER | 01970314 | 05 | NY | MEDICAID | 197255FF | 01 | PREFERRED CARE | OTHER | 000525458004 | 01 | BLUE SHIELD WNY | OTHER | 5610364 | 01 | INDEPENDENT HEALTH | OTHER | P00140112 | 01 | RR MEDICARE | OTHER | P020197363 | 01 | BLUE SHIELD ROCHESTER | OTHER | 00026123305 | 01 | UNIVERA | OTHER | 000525458006 | 01 | BLUE SHIELD WNY | OTHER | 4194144 | 01 | GHI | OTHER | 471306 | 05 | AZ | MEDICAID |