Provider Demographics
NPI:1043615453
Name:JONATHAN SHILL MD
Entity Type:Organization
Organization Name:JONATHAN SHILL MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SHILL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:207-502-7074
Mailing Address - Street 1:26 BARNARD LN
Mailing Address - Street 2:
Mailing Address - City:KENNEBUNK
Mailing Address - State:ME
Mailing Address - Zip Code:04043-6714
Mailing Address - Country:US
Mailing Address - Phone:207-502-7074
Mailing Address - Fax:207-502-7079
Practice Address - Street 1:26 BARNARD LN
Practice Address - Street 2:
Practice Address - City:KENNEBUNK
Practice Address - State:ME
Practice Address - Zip Code:04043-6714
Practice Address - Country:US
Practice Address - Phone:207-502-7074
Practice Address - Fax:207-502-7079
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JONATHAN SHILL MD PHD LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-10-28
Last Update Date:2014-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty