Provider Demographics
NPI:1558429746
Name:SHELLY, MARION I (DO)
Entity Type:Individual
Prefix:MS
First Name:MARION
Middle Name:I
Last Name:SHELLY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 69
Mailing Address - Street 2:BLUFFTON PHYSICIANS INC
Mailing Address - City:BLUFFTON
Mailing Address - State:OH
Mailing Address - Zip Code:45817-0069
Mailing Address - Country:US
Mailing Address - Phone:419-358-5916
Mailing Address - Fax:419-358-2302
Practice Address - Street 1:132 GARAU STREET
Practice Address - Street 2:BLUFFTON PHYSICIANS INC
Practice Address - City:BLUFFTON
Practice Address - State:OH
Practice Address - Zip Code:45817-0069
Practice Address - Country:US
Practice Address - Phone:419-358-5916
Practice Address - Fax:419-358-2302
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2010-01-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OH34006706S207Q00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH10799230OtherCAQH
OH080142390OtherRAILROAD MEDICARE
OH2048797Medicaid
OH00000129735OtherANTHEM
OHSH0843723Medicare ID - Type Unspecified
OH00000129735OtherANTHEM