Basic Information
| Provider Information | |||||||||
| NPI: | 1750318283 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHANAGHAN | ||||||||
| FirstName: | KEVIN | ||||||||
| MiddleName: | JOHN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1341 S ELISEO DR STE 200 | ||||||||
| Address2: | |||||||||
| City: | GREENBRAE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 949042000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4154648169 | ||||||||
| FaxNumber: | 4159259712 | ||||||||
| Practice Location | |||||||||
| Address1: | 1341 S ELISEO DR STE 200 | ||||||||
| Address2: | |||||||||
| City: | GREENBRAE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 949042000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4154648169 | ||||||||
| FaxNumber: | 4159259712 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2006 | ||||||||
| LastUpdateDate: | 07/06/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | OS007370E | PA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | DO2758 | ME | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 20A18062 | CA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 001264101 | 05 | PA | MEDICAID | 0527142000 | 01 | PA | AMERIHEALTH 65 PA | OTHER | P004726 | 01 | PA | GATEWAY-WMG | OTHER | 140375 | 01 | PA | UNISON-WMG HERR'S RIDGE | OTHER | 146180 | 01 | PA | UNISON-WMG THURMONT | OTHER | 20026342 | 01 | PA | AH MERCY-WMG THURMONT | OTHER | 50021844 | 01 | PA | CAPITAL BC-WMG THURMONT | OTHER | 692270 | 01 | PA | HIGHMARK BLUE SHIELD | OTHER | 7429 | 01 | PA | GEISINGER | OTHER | 219458 | 01 | PA | MAMSI-WMG | OTHER | 403896 | 05 | MD | MEDICAID | 50080314 | 01 | PA | CAPITAL BC-WMG-ST.CHARLES | OTHER | 5122170 | 01 | PA | AETNA | OTHER | 080187668 | 01 | PA | RAILROAD MEDICARE | OTHER | 616924 | 01 | MD | CAREFIRST MD BCBS | OTHER | 104877 | 01 | PA | JOHNS HOPKINS | OTHER | 50018543 | 01 | PA | CAPITAL BC-WMG HERR'S RID | OTHER | 20020665 | 01 | PA | AH MERCY-WMG HERR'S RIDGE | OTHER |