MEDICARE: DR. JANN SHIELS MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207VG0400X	Gynecology Physician	22985	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	86-0559827	OTHER		TAX ID #

General Provider Information

NPI Number	:	1235158395
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JANN SHIELS MD

Provider Business Mailing Address
First Line	:	1024 N SAN FRANCISCO ST
Second Line	:	SUITE 105
City	:	FLAGSTAFF
State	:	AZ
Zip	:	86001-3266
Country	:	US
Telephone Number	:	928-779-0341
Fax Number	:	928-774-4994

Provider Business Practice Location Address
First Line	:	1024 N SAN FRANCISCO ST
Second Line	:	SUITE 105
City	:	FLAGSTAFF
State	:	AZ
Zip	:	86001-3266
Country	:	US
Telephone Number	:	928-779-0341
Fax Number	:	928-774-4994

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/19/2006
Last Update Date	:	07/08/2007

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