Healthcare Provider Details

I. General information

NPI: 1194249490
Provider Name (Legal Business Name): SHIELDS RADIOLOGY ASSOCIATES, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2017
Last Update Date: 07/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

265 WESTGATE DR STE 2
BROCKTON MA
02301-1817
US

IV. Provider business mailing address

55 CHRISTY DR
BROCKTON MA
02301-1813
US

V. Phone/Fax

Practice location:
  • Phone: 800-258-4574
  • Fax: 800-253-7569
Mailing address:
  • Phone: 508-897-1501
  • Fax: 508-897-1599

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2085R0203X
TaxonomyTherapeutic Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: STEPHEN T SWERIDUK
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 800-258-4674