Provider Demographics
NPI: | 1669439444 |
---|---|
Name: | SHIVERS, MICHAEL E (MD) |
Entity Type: | Individual |
Prefix: | |
First Name: | MICHAEL |
Middle Name: | E |
Last Name: | SHIVERS |
Suffix: | |
Gender: | M |
Credentials: | MD |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 620 HOWARD AVE |
Mailing Address - Street 2: | |
Mailing Address - City: | ALTOONA |
Mailing Address - State: | PA |
Mailing Address - Zip Code: | 16601-4804 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 814-889-2854 |
Mailing Address - Fax: | 814-889-7982 |
Practice Address - Street 1: | 620 HOWARD AVE |
Practice Address - Street 2: | |
Practice Address - City: | ALTOONA |
Practice Address - State: | PA |
Practice Address - Zip Code: | 16601-4804 |
Practice Address - Country: | US |
Practice Address - Phone: | 814-889-2854 |
Practice Address - Fax: | 814-889-7982 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-04-27 |
Last Update Date: | 2016-01-15 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
PA | MD061239L | 2085R0202X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 2085R0202X | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
PA | 02094901 | Other | CAPITAL BLUE CROSS |
NY | 02662857 | Medicaid | |
MD | 4098026800 | Medicaid | |
PA | 0017715150002 | Medicaid | |
PA | SH750404 | Other | HIGHMARK |
PA | G79255 | Medicare UPIN | |
PA | 0017715150002 | Medicaid |