Provider Demographics
NPI:1821273616
Name:SHACK, TIMOTHY THOMAS (MD)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:THOMAS
Last Name:SHACK
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 1:27 COVERED BRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:CHERRY HILL
Mailing Address - State:NJ
Mailing Address - Zip Code:08034-2945
Mailing Address - Country:US
Mailing Address - Phone:856-429-2224
Mailing Address - Fax:856-429-1926
Practice Address - Street 1:27 COVERED BRIDGE RD
Practice Address - Street 2:
Practice Address - City:CHERRY HILL
Practice Address - State:NJ
Practice Address - Zip Code:08034-2945
Practice Address - Country:US
Practice Address - Phone:856-429-2224
Practice Address - Fax:856-429-1926
Is Sole Proprietor?:No
Enumeration Date:2007-12-31
Last Update Date:2012-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD064207L207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine