Provider Demographics
NPI:1245425206
Name:JACK M. SHIELDS,M.D., PA
Entity Type:Organization
Organization Name:JACK M. SHIELDS,M.D., PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JACK
Authorized Official - Middle Name:M
Authorized Official - Last Name:SHIELDS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:856-455-8833
Mailing Address - Street 1:20 MAGNOLIA AVE
Mailing Address - Street 2:BUILDING B , SUITE C
Mailing Address - City:BRIDGETON
Mailing Address - State:NJ
Mailing Address - Zip Code:08302-1759
Mailing Address - Country:US
Mailing Address - Phone:856-455-8833
Mailing Address - Fax:
Practice Address - Street 1:20 MAGNOLIA AVE
Practice Address - Street 2:BUILDING B , SUITE C
Practice Address - City:BRIDGETON
Practice Address - State:NJ
Practice Address - Zip Code:08302-1759
Practice Address - Country:US
Practice Address - Phone:856-455-8833
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-12
Last Update Date:2007-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA35038207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ3019501Medicaid
NJ3019501Medicaid
NJ888274Medicare PIN
NJ413590DQRMedicare PIN