Basic Information
| Provider Information | |||||||||
| NPI: | 1003852831 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHIELDS | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 RIVER RD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | CONSHOHOCKEN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 194282439 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8003553818 | ||||||||
| FaxNumber: | 6108342862 | ||||||||
| Practice Location | |||||||||
| Address1: | 1771 MADISON ST | ||||||||
| Address2: | |||||||||
| City: | CLARKSVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370434990 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9315526622 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2006 | ||||||||
| LastUpdateDate: | 04/24/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 38487 | TN | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 208100000X | 38487 | TN | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 3893588 | 05 | TN | MEDICAID |