1558429746 NPI number — MS. MARION I SHELLY DO

Table of content: MS. MARION I SHELLY DO (NPI 1558429746)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558429746 NPI number — MS. MARION I SHELLY DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHELLY
Provider First Name:
MARION
Provider Middle Name:
I
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1558429746
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/27/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 69
Provider Second Line Business Mailing Address:
BLUFFTON PHYSICIANS INC
Provider Business Mailing Address City Name:
BLUFFTON
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45817-0069
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
419-358-5916
Provider Business Mailing Address Fax Number:
419-358-2302

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
132 GARAU STREET
Provider Second Line Business Practice Location Address:
BLUFFTON PHYSICIANS INC
Provider Business Practice Location Address City Name:
BLUFFTON
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45817-0069
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
419-358-5916
Provider Business Practice Location Address Fax Number:
419-358-2302
Provider Enumeration Date:
12/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  34006706S , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 208D00000X , with the licence number: 34006706S , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 10799230 . This is a "CAQH" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 080142390 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 2048797 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00000129735 . This is a "ANTHEM" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".




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