Healthcare Provider Details

I. General information

NPI: 1821592254
Provider Name (Legal Business Name): JEFFREY CHARLES SHIRTS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2018
Last Update Date: 06/24/2021
Certification Date: 06/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

980 W IRONWOOD DR STE 302
COEUR D ALENE ID
83814-2668
US

IV. Provider business mailing address

980 W IRONWOOD DR STE 302
COEUR D ALENE ID
83814-2668
US

V. Phone/Fax

Practice location:
  • Phone: 208-292-5437
  • Fax:
Mailing address:
  • Phone: 208-292-5437
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberTRN27183
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberM-15642
License Number StateID
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberTRN27183
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: