Provider Demographics
NPI:1164898557
Name:SHELLY K. BROLINE, M.D., P.A.
Entity Type:Organization
Organization Name:SHELLY K. BROLINE, M.D., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SHELLY
Authorized Official - Middle Name:K
Authorized Official - Last Name:BROLINE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:713-446-2526
Mailing Address - Street 1:8515 HAVEN WAY
Mailing Address - Street 2:
Mailing Address - City:TOMBALL
Mailing Address - State:TX
Mailing Address - Zip Code:77375-2652
Mailing Address - Country:US
Mailing Address - Phone:713-446-2526
Mailing Address - Fax:
Practice Address - Street 1:7501 FANNIN ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77054-1938
Practice Address - Country:US
Practice Address - Phone:281-475-0573
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-19
Last Update Date:2015-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL9112207U00000X, 207UN0901X, 207UN0902X, 2083P0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207U00000XAllopathic & Osteopathic PhysiciansNuclear MedicineGroup - Multi-Specialty
No207UN0901XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear CardiologyGroup - Multi-Specialty
No207UN0902XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear Imaging & TherapyGroup - Multi-Specialty
No2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXI18805Medicare UPIN