Provider Demographics
NPI:1861690422
Name:SHELBY, DIANE C (MED)
Entity type:Individual
Prefix:MS
First Name:DIANE
Middle Name:C
Last Name:SHELBY
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6515 S ROCKWELL ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60629-1735
Mailing Address - Country:US
Mailing Address - Phone:773-737-2169
Mailing Address - Fax:773-737-7226
Practice Address - Street 1:6515 S ROCKWELL ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60629-1735
Practice Address - Country:US
Practice Address - Phone:773-737-2169
Practice Address - Fax:773-737-7226
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILDS39630302P2278S1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2278S1500XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, CertifiedSNF/Subacute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILDS39630302PMedicaid