Healthcare Provider Details

I. General information

NPI: 1992779763
Provider Name (Legal Business Name): JACK W SHILLING MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/16/2006
Last Update Date: 02/04/2020
Certification Date: 02/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 CENTENNIAL BLVD STE 203
VOORHEES NJ
08043-4637
US

IV. Provider business mailing address

1 FEDERAL ST # 200
CAMDEN NJ
08103-1088
US

V. Phone/Fax

Practice location:
  • Phone: 856-325-6677
  • Fax:
Mailing address:
  • Phone: 856-356-4924
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberMD067966L
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number25MA09602700
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: