Provider Demographics
NPI:1306926126
Name:SHELLY, ROBERT J (MD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:J
Last Name:SHELLY
Suffix:
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 1:1713 CROSSFIELD DR
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:PA
Mailing Address - Zip Code:17603-6789
Mailing Address - Country:US
Mailing Address - Phone:717-735-6808
Mailing Address - Fax:
Practice Address - Street 1:625 S DUKE ST
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:PA
Practice Address - Zip Code:17602-4509
Practice Address - Country:US
Practice Address - Phone:717-299-6371
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2021-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY208628207R00000X, 208000000X
PAMD473284207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03322323Medicaid
NY03322323Medicaid