Healthcare Provider Details

I. General information

NPI: 1245425206
Provider Name (Legal Business Name): JACK M. SHIELDS,M.D., PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/12/2007
Last Update Date: 09/13/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 MAGNOLIA AVE BUILDING B , SUITE C
BRIDGETON NJ
08302-1759
US

IV. Provider business mailing address

20 MAGNOLIA AVE BUILDING B , SUITE C
BRIDGETON NJ
08302-1759
US

V. Phone/Fax

Practice location:
  • Phone: 856-455-8833
  • Fax:
Mailing address:
  • Phone: 856-455-8833
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMA35038
License Number StateNJ

VIII. Authorized Official

Name: JACK M. SHIELDS
Title or Position: CEO/PRESIDENT
Credential: M.D.
Phone: 856-455-8833