1669462149 NPI number — CAROLE E SHELLEY M.D.

Table of content: CAROLE E SHELLEY M.D. (NPI 1669462149)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669462149 NPI number — CAROLE E SHELLEY M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHELLEY
Provider First Name:
CAROLE
Provider Middle Name:
E
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1669462149
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/19/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
777 HOSPITAL WAY
Provider Second Line Business Mailing Address:
SUTIE 300
Provider Business Mailing Address City Name:
POCATELLO
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83201-5176
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-239-3461
Provider Business Mailing Address Fax Number:
208-239-3425

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
777 HOSPITAL WAY
Provider Second Line Business Practice Location Address:
SUITE 300
Provider Business Practice Location Address City Name:
POCATELLO
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83201-5176
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-239-3461
Provider Business Practice Location Address Fax Number:
208-239-3425
Provider Enumeration Date:
10/25/2005

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: 207V00000X , with the licence number:  31911 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207V00000X , with the licence number: M-10122 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 829335 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 77366 . This is a "BLUE CROSS OF IDAHO" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 808067800 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 82-0503971 . This is a "RAILROAD-MEDICARE" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".




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