Provider Demographics
NPI:1083656060
Name:SHELLY, KEVIN R (MD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:R
Last Name:SHELLY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:8140 N MOPAC EXPY BLDG III
Mailing Address - Street 2:SUITE 210
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78759-8837
Mailing Address - Country:US
Mailing Address - Phone:512-343-2292
Mailing Address - Fax:512-343-2745
Practice Address - Street 1:8140 N MOPAC EXPY BLDG III
Practice Address - Street 2:SUITE 210
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78759-8837
Practice Address - Country:US
Practice Address - Phone:512-343-2292
Practice Address - Fax:512-343-2745
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2008-11-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXK6504207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8AG658OtherBCBS
TXH36461Medicare UPIN
TX8L0148Medicare PIN