Provider Demographics
NPI:1740235886
Name:LALL, SHELLY C (MD)
Entity Type:Individual
Prefix:
First Name:SHELLY
Middle Name:C
Last Name:LALL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1221 SIXTH STREET
Mailing Address - Street 2:SUITE 202
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-2359
Mailing Address - Country:US
Mailing Address - Phone:231-935-5730
Mailing Address - Fax:231-935-5736
Practice Address - Street 1:1221 SIXTH STREET
Practice Address - Street 2:SUITE 202
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-2359
Practice Address - Country:US
Practice Address - Phone:717-531-8521
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2014-03-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO2005027553208600000X
MI4301099915208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
No208600000XAllopathic & Osteopathic PhysiciansSurgery