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General NPI Number Information
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NPI Number | 1245425206
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Entity Type | Organization
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Legal Business Name | JACK M. SHIELDS,M.D., PA
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Dates
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Enumeration Date | 09/12/2007
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Last Update Date | 09/13/2007
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Provider Practice Location Address
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Address Line | 20 MAGNOLIA AVE BUILDING B , SUITE C
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City | BRIDGETON
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State | NJ
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Zip | 08302-1759
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Country | US
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Telephone | 856-455-8833
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Fax |
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Provider Business Mailing Address
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Address Line | 20 MAGNOLIA AVE BUILDING B , SUITE C
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City | BRIDGETON
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State | NJ
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Zip | 08302-1759
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Country | US
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Telephone | 856-455-8833
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Fax |
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Authorized Official
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Title or Position | CEO/PRESIDENT
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Name | JACK M. SHIELDS
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Credential | M.D.
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Telephone | 856-455-8833
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | MA35038
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License Number State | NJ
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