Healthcare Provider Details

I. General information

NPI: 1891792651
Provider Name (Legal Business Name): MICHAEL C SHOCKLEY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2005
Last Update Date: 04/20/2022
Certification Date: 04/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

705 GARFIELD AVE SUITE 400
PARKERSBURG WV
26101-5444
US

IV. Provider business mailing address

705 GARFIELD AVE SUITE 400
PARKERSBURG WV
26101-5444
US

V. Phone/Fax

Practice location:
  • Phone: 304-485-4700
  • Fax: 304-485-4466
Mailing address:
  • Phone: 304-485-4700
  • Fax: 304-485-4466

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number17290
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number35065899
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code207VX0000X
TaxonomyObstetrics Physician
License Number35065899
License Number StateOH
# 4
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number17290
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: