Healthcare Provider Details

I. General information

NPI: 1518925718
Provider Name (Legal Business Name): MICHAEL GRAY SHELL D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2006
Last Update Date: 07/16/2021
Certification Date: 07/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1551 PROFESSIONAL LN UNIT 180
LONGMONT CO
80501-6970
US

IV. Provider business mailing address

1551 PROFESSIONAL LN UNIT 180
LONGMONT CO
80501-6970
US

V. Phone/Fax

Practice location:
  • Phone: 720-476-3421
  • Fax: 720-502-5271
Mailing address:
  • Phone: 720-307-7246
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number35565
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: