Healthcare Provider Details

I. General information

NPI: 1578504528
Provider Name (Legal Business Name): MARK EDWARD SHIRLEY D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2006
Last Update Date: 05/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

810 N 22ND ST
BLAIR NE
68008
US

IV. Provider business mailing address

810 N 22ND ST
BLAIR NE
68008-1128
US

V. Phone/Fax

Practice location:
  • Phone: 402-426-2182
  • Fax: 402-426-1190
Mailing address:
  • Phone: 402-426-2182
  • Fax: 402-426-1190

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number179
License Number StateNE
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number179
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: