Provider Demographics
NPI:1760485593
Name:DEWITT, MICHAEL SHANE (DO)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:SHANE
Last Name:DEWITT
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4605 MACCORKLE AVE SW
Mailing Address - Street 2:THS PHYSICIAN PARTNERS, INC.-ADMIN OFC
Mailing Address - City:SOUTH CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25309-1311
Mailing Address - Country:US
Mailing Address - Phone:304-414-4800
Mailing Address - Fax:304-414-4801
Practice Address - Street 1:506 CHESTNUT STREET
Practice Address - Street 2:
Practice Address - City:SOUTH CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25309-1402
Practice Address - Country:US
Practice Address - Phone:304-766-8558
Practice Address - Fax:304-766-8561
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2021-12-22
Deactivation Date:2006-03-17
Deactivation Code:
Reactivation Date:2006-03-22
Provider Licenses
StateLicense IDTaxonomies
WV1255207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0053306000Medicaid
WVB441OtherGROUP MEDICARE
WV3810024049OtherGROUP MEDICAID
WVF30643Medicare UPIN
WV0053306000Medicaid
WV0053306000Medicaid