Provider Demographics
NPI:1891724688
Name:PATTERSON, MICHAEL SHANE (DO)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:SHANE
Last Name:PATTERSON
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 1:44720 VAN DYKE AVE
Mailing Address - Street 2:
Mailing Address - City:UTICA
Mailing Address - State:MI
Mailing Address - Zip Code:48317-5480
Mailing Address - Country:US
Mailing Address - Phone:586-221-2791
Mailing Address - Fax:586-231-0716
Practice Address - Street 1:44720 VAN DYKE AVE
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:MI
Practice Address - Zip Code:48317-5480
Practice Address - Country:US
Practice Address - Phone:586-323-7148
Practice Address - Fax:586-323-7215
Is Sole Proprietor?:No
Enumeration Date:2006-07-02
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101014038204D00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI700E031600OtherBCBS GROUP NUMBER
MI11-5501033-5OtherBCBS PIN
MI11-5501033-5OtherBCBS PIN
MIMI3996032Medicare PIN
MAH83888Medicare UPIN
MIMI3996Medicare PIN
MI700E012740OtherBCBS GROUP NUMBER