Provider Demographics
NPI:1356426639
Name:GELONECK, SHELLY J (PA)
Entity type:Individual
Prefix:
First Name:SHELLY
Middle Name:J
Last Name:GELONECK
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:SHELLY
Other - Middle Name:J
Other - Last Name:BIBLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:7700 WASHINGTON VILLAGE DR STE 220
Mailing Address - Street 2:
Mailing Address - City:CENTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45459-4094
Mailing Address - Country:US
Mailing Address - Phone:937-438-3132
Mailing Address - Fax:937-438-0902
Practice Address - Street 1:7700 WASHINGTON VILLAGE DR STE 220
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:45459-4094
Practice Address - Country:US
Practice Address - Phone:937-438-3132
Practice Address - Fax:937-438-0902
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH41.5001363A00000X
OH50.001999363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH383047893OtherANTHEM BC/BS
OH383047893OtherAETNA
OH383047893OtherUNITED HEALTH CARE
OH0105384Medicaid
OH383047893OtherANTHEM BC/BS
OHQ09167Medicare UPIN
OHPA22603Medicare ID - Type Unspecified