Provider Demographics
NPI:1114904240
Name:SHELL, EDDIE G II (MD)
Entity Type:Individual
Prefix:
First Name:EDDIE
Middle Name:G
Last Name:SHELL
Suffix:II
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 1:120 E BEAUREGARD AVE
Mailing Address - Street 2:
Mailing Address - City:SAN ANGELO
Mailing Address - State:TX
Mailing Address - Zip Code:76903-5919
Mailing Address - Country:US
Mailing Address - Phone:325-374-1436
Mailing Address - Fax:
Practice Address - Street 1:120 E BEAUREGARD AVE
Practice Address - Street 2:
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76903-5919
Practice Address - Country:US
Practice Address - Phone:325-658-1511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-29
Last Update Date:2019-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL05932085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8M1836OtherBCBS
TX151500906Medicaid
TX151500905Medicaid
TXP00146117OtherMEDICARE RAILROAD
TXP00306677OtherMEDICARE RAILROAD
TX8M2152OtherBCBS
TXH62208Medicare UPIN
TX8G5778Medicare ID - Type Unspecified
TX151500906Medicaid