Healthcare Provider Details

I. General information

NPI: 1730165366
Provider Name (Legal Business Name): JEFFREY S SHILT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/15/2005
Last Update Date: 02/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

703 S AMERICANA BLVD STE 120
BOISE ID
83702-5099
US

IV. Provider business mailing address

190 E BANNOCK ST
BOISE ID
83712-6241
US

V. Phone/Fax

Practice location:
  • Phone: 208-323-2600
  • Fax:
Mailing address:
  • Phone: 208-381-2222
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number9901473
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code207XP3100X
TaxonomyPediatric Orthopaedic Surgery Physician
License NumberM10261
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: