Healthcare Provider Details

I. General information

NPI: 1578484556
Provider Name (Legal Business Name): ISAAC SHELLY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/23/2026
Last Update Date: 07/23/2026
Certification Date: 07/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1834 S 2ND AVE
MAYWOOD IL
60153-3306
US

IV. Provider business mailing address

1834 S 2ND AVE
MAYWOOD IL
60153-3306
US

V. Phone/Fax

Practice location:
  • Phone: 708-415-4204
  • Fax:
Mailing address:
  • Phone: 708-415-4204
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172P00000X
TaxonomyNaprapath
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: