Provider Demographics
NPI:1215920236
Name:SHELY, WILLIAM WALTER III (MD)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:WALTER
Last Name:SHELY
Suffix:III
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 1:975 SE SANDY BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-1308
Mailing Address - Country:US
Mailing Address - Phone:503-963-2846
Mailing Address - Fax:503-963-9505
Practice Address - Street 1:875 OAK ST SE
Practice Address - Street 2:SUITE 5020
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-3975
Practice Address - Country:US
Practice Address - Phone:503-371-4044
Practice Address - Fax:503-371-4356
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-24
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD14793208G00000X
WAMD00033156208G00000X
CAG68679208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8178899Medicaid
OR073705Medicaid
WA8178899Medicaid
WAAB37914Medicare ID - Type UnspecifiedVANCOUVER
OR115781Medicare ID - Type UnspecifiedSALEM
OR073705Medicaid