Provider Demographics
NPI:1093102378
Name:SHELEY, MITCHELL (MD)
Entity Type:Individual
Prefix:
First Name:MITCHELL
Middle Name:
Last Name:SHELEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N2950 STATE ROAD 67
Mailing Address - Street 2:
Mailing Address - City:LAKE GENEVA
Mailing Address - State:WI
Mailing Address - Zip Code:53147-2655
Mailing Address - Country:US
Mailing Address - Phone:608-756-6871
Mailing Address - Fax:262-245-2248
Practice Address - Street 1:N2950 STATE ROAD 67
Practice Address - Street 2:
Practice Address - City:LAKE GENEVA
Practice Address - State:WI
Practice Address - Zip Code:53147-2655
Practice Address - Country:US
Practice Address - Phone:608-756-6871
Practice Address - Fax:262-245-2248
Is Sole Proprietor?:No
Enumeration Date:2015-04-23
Last Update Date:2019-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0085181207P00000X
WI71253-20207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine