Provider Demographics
NPI:1578769766
Name:SHELLENBERGER, WALLACE (MD)
Entity Type:Individual
Prefix:
First Name:WALLACE
Middle Name:
Last Name:SHELLENBERGER
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 1:2845 N. COUNTY RD. W.
Mailing Address - Street 2:
Mailing Address - City:PAOLI
Mailing Address - State:IN
Mailing Address - Zip Code:47454
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:488 W HOSPITAL RD
Practice Address - Street 2:
Practice Address - City:PAOLI
Practice Address - State:IN
Practice Address - Zip Code:47454-8807
Practice Address - Country:US
Practice Address - Phone:812-723-4301
Practice Address - Fax:812-723-4306
Is Sole Proprietor?:No
Enumeration Date:2007-06-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN010205152084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN210780CMedicare ID - Type Unspecified
INB29092Medicare UPIN