Provider Demographics
NPI:1962460303
Name:LIVELY, MICHAEL SHAWN (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:SHAWN
Last Name:LIVELY
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 1:1845 FOOTHILLS DR
Mailing Address - Street 2:
Mailing Address - City:KERRVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78028-3873
Mailing Address - Country:US
Mailing Address - Phone:717-246-9097
Mailing Address - Fax:
Practice Address - Street 1:710 WATER ST
Practice Address - Street 2:
Practice Address - City:KERRVILLE
Practice Address - State:TX
Practice Address - Zip Code:78028-5329
Practice Address - Country:US
Practice Address - Phone:830-258-7747
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-03
Last Update Date:2009-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM3632207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8M6794OtherBCBS
TX180018702OtherCSHCN
TX180018701Medicaid
TX8G5960Medicare PIN
TX8M6794OtherBCBS
TX180018701Medicaid
TX180018702OtherCSHCN