Healthcare Provider Details

I. General information

NPI: 1356862148
Provider Name (Legal Business Name): JONATHAN MCCLAIN SHIELDS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2017
Last Update Date: 07/21/2022
Certification Date: 12/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

981150 NEBRASKA MEDICAL CTR
OMAHA NE
68198-1150
US

IV. Provider business mailing address

981150 NEBRASKA MEDICAL CTR
OMAHA NE
68198-1150
US

V. Phone/Fax

Practice location:
  • Phone: 402-559-6802
  • Fax: 402-559-9659
Mailing address:
  • Phone: 402-559-6802
  • Fax: 402-559-9659

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number47432
License Number StateIA
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number8111
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: