Provider Demographics
NPI:1548265598
Name:BROLINE, SHELLY KRISTIN (MD)
Entity type:Individual
Prefix:DR
First Name:SHELLY
Middle Name:KRISTIN
Last Name:BROLINE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8515 HAVEN WAY
Mailing Address - Street 2:
Mailing Address - City:TOMBALL
Mailing Address - State:TX
Mailing Address - Zip Code:77375-2652
Mailing Address - Country:US
Mailing Address - Phone:713-446-2526
Mailing Address - Fax:
Practice Address - Street 1:7501 FANNIN ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77054-1938
Practice Address - Country:US
Practice Address - Phone:281-674-8643
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2015-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL91122085N0904X, 207U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear Radiology
No207U00000XAllopathic & Osteopathic PhysiciansNuclear Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXI18805Medicare UPIN
TXTXB112731Medicare PIN
TXP00691948Medicare PIN
TXTXB104727Medicare PIN
TXTXB112731Medicare PIN
TX8K6962Medicare PIN
TX168839202Medicaid
TXI18805Medicare UPIN
TX168839203Medicaid