Basic Information
| Provider Information | |||||||||
| NPI: | 1730180126 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHELLY | ||||||||
| FirstName: | RANDAL | ||||||||
| MiddleName: | LUCAS | ||||||||
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| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 785 5TH AVENUE | ||||||||
| Address2: | SUITE 3 | ||||||||
| City: | CHAMBERSBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 172014232 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7172639555 | ||||||||
| FaxNumber: | 7172174217 | ||||||||
| Practice Location | |||||||||
| Address1: | 112 N 7TH ST | ||||||||
| Address2: | |||||||||
| City: | CHAMBERSBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 172011720 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7172174300 | ||||||||
| FaxNumber: | 7172174217 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2005 | ||||||||
| LastUpdateDate: | 02/05/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 02/05/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | OS010845L | PA | N | Allopathic & Osteopathic Physicians | Family Medicine | 208M00000X | OS010845L | PA | Y | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 1533687 | 01 | PA | GATEWAY (WH) | OTHER | 172970 | 01 | PA | UNISON | OTHER | 50087606 | 01 | PA | CAPITAL BLUECROSS (WH) | OTHER | 867633 | 01 | PA | MEDICARE GROUP # | OTHER | 277524 | 01 | PA | MAMSI | OTHER | BS7019791 | 01 | PA | DEA | OTHER | 080180776 | 01 | PA | RAILROAD MEDICARE | OTHER | 25-1716306 | 01 | PA | GREATWEST HEALTHCARE | OTHER | 25-1716306 | 01 | PA | DEVON | OTHER | 25-1716306 | 01 | PA | HEALTHNET/TRICARE | OTHER | 308445 | 01 | PA | HEALTH AMERICA | OTHER | P006022 | 01 | PA | GATEWAY (CH) | OTHER | 1007307260034 | 01 | PA | MEDICAID GROUP # | OTHER | 2198371 | 01 | PA | FIRST HEALTH | OTHER | OS010845L | 01 | PA | LICENSE | OTHER | 120420410 | 01 | PA | DEPT OF LABOR | OTHER | 25-1716306 | 01 | PA | INTERGROUP | OTHER | 25-1716306 | 01 | PA | INFORMED | OTHER | 7437368 | 01 | PA | AETNA NON-HMO | OTHER | 85320 | 01 | PA | HIGHMARK BLUESHIELD | OTHER | 25-1716306 | 01 | PA | MULTIPLAN/PHCS | OTHER | 2890315 | 01 | PA | AETNA HMO | OTHER | 50045001 | 01 | PA | CAPITAL BLUECROSS (CH) | OTHER | 0018237650007 | 05 | PA | MEDICAID | 25-1716306 | 01 | PA | SOUTH CENTRAL PREFERRED | OTHER |