Provider Demographics
NPI:1679571053
Name:SHORTELL, ROBERT M (DC)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:M
Last Name:SHORTELL
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 BREEZY CORNERS RD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:CT
Mailing Address - Zip Code:06480-1711
Mailing Address - Country:US
Mailing Address - Phone:860-342-1636
Mailing Address - Fax:
Practice Address - Street 1:28 SHUNPIKE RD
Practice Address - Street 2:
Practice Address - City:CROMWELL
Practice Address - State:CT
Practice Address - Zip Code:06416-2454
Practice Address - Country:US
Practice Address - Phone:860-635-4455
Practice Address - Fax:860-635-0499
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001242111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004178035Medicaid
CTU67120Medicare UPIN
CT350000948Medicare ID - Type Unspecified