1760485593 NPI number — DR. MICHAEL SHANE DEWITT D.O.

Table of content: DR. MICHAEL SHANE DEWITT D.O. (NPI 1760485593)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760485593 NPI number — DR. MICHAEL SHANE DEWITT D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DEWITT
Provider First Name:
MICHAEL
Provider Middle Name:
SHANE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.O.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1760485593
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/22/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
03/17/2006
NPI Reactivation Date:
03/22/2006

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4605 MACCORKLE AVE SW
Provider Second Line Business Mailing Address:
THS PHYSICIAN PARTNERS, INC.-ADMIN OFC
Provider Business Mailing Address City Name:
SOUTH CHARLESTON
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
25309-1311
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-414-4800
Provider Business Mailing Address Fax Number:
304-414-4801

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
506 CHESTNUT STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOUTH CHARLESTON
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
25309-1402
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-766-8558
Provider Business Practice Location Address Fax Number:
304-766-8561
Provider Enumeration Date:
05/24/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  1255 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)