Provider Demographics
NPI:1215238357
Name:SHANE WOOLEVER DO PC
Entity type:Organization
Organization Name:SHANE WOOLEVER DO PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SHANE
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:WOOLEVER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:906-635-5100
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-05
Last Update Date:2010-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101013704207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4361305Medicaid
MI4361305Medicaid
0N39440Medicare PIN