Provider Demographics
NPI:1730180126
Name:SHELLY, RANDAL LUCAS (DO)
Entity type:Individual
Prefix:
First Name:RANDAL
Middle Name:LUCAS
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 1:100 N ACADEMY AVE
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17822-4903
Mailing Address - Country:US
Mailing Address - Phone:570-271-6144
Mailing Address - Fax:
Practice Address - Street 1:400 HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:LEWISTOWN
Practice Address - State:PA
Practice Address - Zip Code:17044-1167
Practice Address - Country:US
Practice Address - Phone:717-248-5411
Practice Address - Fax:717-242-7581
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2025-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS010845L208M00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA080180776OtherRAILROAD MEDICARE
PA25-1716306OtherHEALTHNET/TRICARE
PA25-1716306OtherMULTIPLAN/PHCS
PA2890315OtherAETNA HMO
PA50045001OtherCAPITAL BLUECROSS (CH)
PAP006022OtherGATEWAY (CH)
PA7437368OtherAETNA NON-HMO
PA25-1716306OtherINTERGROUP
PA25-1716306OtherINFORMED
PA308445OtherHEALTH AMERICA
PA50087606OtherCAPITAL BLUECROSS (WH)
PA120420410OtherDEPT OF LABOR
PA2198371OtherFIRST HEALTH
PA25-1716306OtherDEVON
PA25-1716306OtherSOUTH CENTRAL PREFERRED
PA1533687OtherGATEWAY (WH)
PA25-1716306OtherGREATWEST HEALTHCARE
PA277524OtherMAMSI
PA85320OtherHIGHMARK BLUESHIELD
PAOS010845LOtherLICENSE
PA1007307260034OtherMEDICAID GROUP #
PA867633OtherMEDICARE GROUP #
PA0018237650007Medicaid
PA172970OtherUNISON
PA25-1716306OtherSOUTH CENTRAL PREFERRED
PA25-1716306OtherDEVON
PA25-1716306OtherMULTIPLAN/PHCS