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General NPI Number Information
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NPI Number | 1730119934
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Entity Type | Individual
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Provider Name | JACK M SHIELDS M.D.
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Gender | Male
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Dates
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Enumeration Date | 07/03/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 20 MAGNOLIA AVE 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 | 856-453-8358
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Provider Business Mailing Address
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Address Line | 20 MAGNOLIA AVE 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 | 856-453-8358
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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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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