1285680553 NPI number — MARY ELLEN THERESA SHIELDS M.D.

Table of content: MARY ELLEN THERESA SHIELDS M.D. (NPI 1285680553)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285680553 NPI number — MARY ELLEN THERESA SHIELDS M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHIELDS
Provider First Name:
MARY ELLEN
Provider Middle Name:
THERESA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1285680553
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/05/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 936
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LONDON
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40743-0936
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
859-986-8418
Provider Business Mailing Address Fax Number:
859-986-6568

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
305 ESTILL ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BEREA
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40403-1742
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
859-986-8418
Provider Business Practice Location Address Fax Number:
859-986-6568
Provider Enumeration Date:
05/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208600000X , with the licence number:  30354 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 64303548 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00357584 . This is a "RRMC" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com