Provider Demographics
NPI:1679517114
Name:SHELEY, ROBERT C (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:C
Last Name:SHELEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 3730
Mailing Address - Street 2:#DINW103
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3730
Mailing Address - Country:US
Mailing Address - Phone:800-878-6698
Mailing Address - Fax:913-234-1108
Practice Address - Street 1:1015 NW 22ND AVE
Practice Address - Street 2:STE T240
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-3025
Practice Address - Country:US
Practice Address - Phone:503-413-7127
Practice Address - Fax:503-227-0218
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2011-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD161572085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR016100Medicaid
OR016100Medicaid
104204Medicare ID - Type Unspecified