Provider Demographics
NPI:1306879226
Name:SHELLY, RYAN T (DO)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:T
Last Name:SHELLY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 N 7TH ST
Mailing Address - Street 2:
Mailing Address - City:CHAMBERSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17201-1720
Mailing Address - Country:US
Mailing Address - Phone:717-267-7146
Mailing Address - Fax:717-267-7728
Practice Address - Street 1:112 N 7TH ST
Practice Address - Street 2:
Practice Address - City:CHAMBERSBURG
Practice Address - State:PA
Practice Address - Zip Code:17201-1720
Practice Address - Country:US
Practice Address - Phone:717-267-7146
Practice Address - Fax:717-267-7728
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2020-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS012287207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102235887Medicaid
103398G0EMedicare PIN
P00335874Medicare PIN