Provider Demographics
NPI:1669462149
Name:SHELLEY, CAROLE E (MD)
Entity Type:Individual
Prefix:
First Name:CAROLE
Middle Name:E
Last Name:SHELLEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:777 HOSPITAL WAY
Mailing Address - Street 2:SUTIE 300
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-5176
Mailing Address - Country:US
Mailing Address - Phone:208-239-3461
Mailing Address - Fax:208-239-3425
Practice Address - Street 1:777 HOSPITAL WAY
Practice Address - Street 2:SUITE 300
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-5176
Practice Address - Country:US
Practice Address - Phone:208-239-3461
Practice Address - Fax:208-239-3425
Is Sole Proprietor?:No
Enumeration Date:2005-10-25
Last Update Date:2012-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ31911207V00000X
IDM-10122207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ829335Medicaid
ID77366OtherBLUE CROSS OF IDAHO
ID808067800Medicaid
ID82-0503971OtherRAILROAD-MEDICARE
ID82-0503971OtherRAILROAD-MEDICARE
ID77366OtherBLUE CROSS OF IDAHO