Provider Demographics
NPI:1780666461
Name:SHIVELY, THEODORE WILLIAM (DO)
Entity Type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:WILLIAM
Last Name:SHIVELY
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 1:39555 W 10 MILE RD
Mailing Address - Street 2:SUITE 302
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48375-2950
Mailing Address - Country:US
Mailing Address - Phone:248-426-7200
Mailing Address - Fax:
Practice Address - Street 1:39555 W 10 MILE RD
Practice Address - Street 2:SUITE 302
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48375-2950
Practice Address - Country:US
Practice Address - Phone:248-426-7200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-17
Last Update Date:2011-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101007588207Q00000X, 207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4233780Medicaid
MI4233780Medicaid
MI0N141770001Medicare PIN