MEDICARE: MR. JEROME W. SHELL II

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	176P00000X	Funeral Director	011546L	PA

General Provider Information

NPI Number	:	1942411756
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JEROME W. SHELL II

Provider Business Mailing Address
First Line	:	164 S MOUNT VERNON AVE
Second Line	:
City	:	UNIONTOWN
State	:	PA
Zip	:	15401-3226
Country	:	US
Telephone Number	:	724-437-2081
Fax Number	:	724-437-4095

Provider Business Practice Location Address
First Line	:	164 S MOUNT VERNON AVE
Second Line	:
City	:	UNIONTOWN
State	:	PA
Zip	:	15401-3226
Country	:	US
Telephone Number	:	724-437-2081
Fax Number	:	724-437-4095

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/24/2007
Last Update Date	:	07/08/2007

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