MEDICARE: RANDAL LUCAS SHELLY DO

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	208M00000X	Hospitalist Physician	OS010845L	PA
2	207Q00000X	Family Medicine Physician	OS010845L	PA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	080180776	OTHER	PA	RAILROAD MEDICARE
22	867633	OTHER	PA	MEDICARE GROUP #

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	25-1716306	OTHER	PA	HEALTHNET/TRICARE
3	25-1716306	OTHER	PA	MULTIPLAN/PHCS
4	2890315	OTHER	PA	AETNA HMO
5	50045001	OTHER	PA	CAPITAL BLUECROSS (CH)
6	P006022	OTHER	PA	GATEWAY (CH)
7	7437368	OTHER	PA	AETNA NON-HMO
8	25-1716306	OTHER	PA	INTERGROUP
9	25-1716306	OTHER	PA	INFORMED
10	308445	OTHER	PA	HEALTH AMERICA
11	50087606	OTHER	PA	CAPITAL BLUECROSS (WH)
12	120420410	OTHER	PA	DEPT OF LABOR
13	2198371	OTHER	PA	FIRST HEALTH
14	25-1716306	OTHER	PA	DEVON
15	25-1716306	OTHER	PA	SOUTH CENTRAL PREFERRED
16	1533687	OTHER	PA	GATEWAY (WH)
17	25-1716306	OTHER	PA	GREATWEST HEALTHCARE
18	277524	OTHER	PA	MAMSI
19	85320	OTHER	PA	HIGHMARK BLUESHIELD
20	OS010845L	OTHER	PA	LICENSE
21	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
23	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
24	172970	OTHER	PA	UNISON

General Provider Information

NPI Number	:	1730180126
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RANDAL LUCAS SHELLY DO

Provider Business Mailing Address
First Line	:	100 N ACADEMY AVE
Second Line	:
City	:	DANVILLE
State	:	PA
Zip	:	17822-4903
Country	:	US
Telephone Number	:	570-271-6144
Fax Number	:

Provider Business Practice Location Address
First Line	:	400 HIGHLAND AVE
Second Line	:
City	:	LEWISTOWN
State	:	PA
Zip	:	17044-1167
Country	:	US
Telephone Number	:	717-248-5411
Fax Number	:	717-242-7581

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

Provider Enumeration Date	:	08/09/2005
Last Update Date	:	04/07/2025

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