Basic Information
| Provider Information | |||||||||
| NPI: | 1184602963 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOWEN | ||||||||
| FirstName: | SHANE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 501 MORRIS ST | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 253011326 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8008750136 | ||||||||
| FaxNumber: | 9376194381 | ||||||||
| Practice Location | |||||||||
| Address1: | 3200 MACCORKLE AVE SE | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 253041227 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043884170 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/03/2006 | ||||||||
| LastUpdateDate: | 01/24/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 18065 | WV | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0126718000 | 05 | WV | MEDICAID | 1036688 | 01 | WV | CH WV DWC | OTHER | 2333157 | 05 | OH | MEDICAID | 3001167 | 01 | WV | WORKERS COMPENSATION | OTHER | 001718054 | 01 | WV | BLUE CROSS BLUE SHIELD | OTHER | 64051394 | 05 | KY | MEDICAID |