=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508861949
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PAUL EUGENE SHIELDS DO
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/14/2005
-----------------------------------------------------
Last Update Date | 10/10/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2501 W 12TH ST SUITE 1
-----------------------------------------------------
City | ERIE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 16505-4527
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 814-806-1144
-----------------------------------------------------
Fax | 814-833-0659
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 397 CHURCHILL HUBBARD RD
-----------------------------------------------------
City | YOUNGSTOWN
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44505-1375
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-759-6750
-----------------------------------------------------
Fax | 330-759-6755
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | OS010676L
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------