Provider Demographics
NPI:1790851830
Name:WOOLEVER, SHANE MICHAEL (DO)
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:MICHAEL
Last Name:WOOLEVER
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 1:146 W SPRUCE ST
Mailing Address - Street 2:
Mailing Address - City:SAULT SAINTE MARIE
Mailing Address - State:MI
Mailing Address - Zip Code:49783-1912
Mailing Address - Country:US
Mailing Address - Phone:906-635-5100
Mailing Address - Fax:906-635-1143
Practice Address - Street 1:146 W SPRUCE ST
Practice Address - Street 2:
Practice Address - City:SAULT SAINTE MARIE
Practice Address - State:MI
Practice Address - Zip Code:49783-1912
Practice Address - Country:US
Practice Address - Phone:906-635-5100
Practice Address - Fax:906-635-1143
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101013704207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MISW013704OtherMICHIGAN LICENSE NUMBER
MI4361305Medicaid
MI5170026OtherBCBS
MI5170026OtherBCBS
MIH51755Medicare UPIN