Provider Demographics
NPI:1760400873
Name:SHIELDS, THOMAS W (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:W
Last Name:SHIELDS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2080
Mailing Address - Street 2:
Mailing Address - City:KILMARNOCK
Mailing Address - State:VA
Mailing Address - Zip Code:22482-2080
Mailing Address - Country:US
Mailing Address - Phone:804-435-3508
Mailing Address - Fax:
Practice Address - Street 1:320 HOSPITAL DR
Practice Address - Street 2:EMERGENCY DEPT.
Practice Address - City:MARTINSVILLE
Practice Address - State:VA
Practice Address - Zip Code:24112-1900
Practice Address - Country:US
Practice Address - Phone:276-666-7200
Practice Address - Fax:276-666-7600
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2008-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101221408207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC790593QMedicaid
VA005827621Medicaid
930001554Medicare PIN
G97080Medicare UPIN