Provider Demographics
NPI:1871827527
Name:SHIELDS FAMILY CLINIC
Entity Type:Organization
Organization Name:SHIELDS FAMILY CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:BERNARD
Authorized Official - Last Name:SHIELDS
Authorized Official - Suffix:
Authorized Official - Credentials:ARNP
Authorized Official - Phone:270-776-3381
Mailing Address - Street 1:1030 BROOKHAVEN RD
Mailing Address - Street 2:PO BOX 346
Mailing Address - City:FRANKLIN
Mailing Address - State:KY
Mailing Address - Zip Code:42135-0346
Mailing Address - Country:US
Mailing Address - Phone:270-586-1800
Mailing Address - Fax:
Practice Address - Street 1:1030 BROOKHAVEN RD
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:KY
Practice Address - Zip Code:42134-2745
Practice Address - Country:US
Practice Address - Phone:270-586-1800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-29
Last Update Date:2009-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY6167363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAQ20916Medicare UPIN