Provider Demographics
NPI:1184602963
Name:BOWEN, SHANE (MD)
Entity type:Individual
Prefix:DR
First Name:SHANE
Middle Name:
Last Name:BOWEN
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 1:501 MORRIS ST
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25301-1326
Mailing Address - Country:US
Mailing Address - Phone:800-875-0136
Mailing Address - Fax:937-619-4381
Practice Address - Street 1:3200 MACCORKLE AVE SE
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25304-1227
Practice Address - Country:US
Practice Address - Phone:304-388-4170
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-03
Last Update Date:2023-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV18065207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2333157Medicaid
WV0126718000Medicaid
KY64051394Medicaid
WV3001167OtherWORKERS COMPENSATION
WV001718054OtherBLUE CROSS BLUE SHIELD
WV1036688OtherCH WV DWC
WVBO0859553Medicare PIN
WV0126718000Medicaid
WVBO0859552Medicare PIN
WVP00298963Medicare PIN
WVBO0859556Medicare PIN
WV930118818Medicare PIN
WV930114605Medicare PIN