Basic Information
| Provider Information | |||||||||
| NPI: | 1013975895 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHIELDS | ||||||||
| FirstName: | GREGORY | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1368 | ||||||||
| Address2: | |||||||||
| City: | WILLIAMSVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142311368 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168592954 | ||||||||
| FaxNumber: | 7168592962 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 HIGH ST | ||||||||
| Address2: | |||||||||
| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142031126 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168592954 | ||||||||
| FaxNumber: | 7168592962 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2006 | ||||||||
| LastUpdateDate: | 05/06/2008 | ||||||||
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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 | 2085R0202X | 234818 | NY | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 00027018401 | 01 | UNIVERA | OTHER | 195358FF | 01 | PREFERRED CARE | OTHER | P010234818 | 01 | BLUE CHOICE | OTHER | 000528027007 | 01 | BLUE SHIELD WNY | OTHER | 00027018407 | 01 | UNIVERA | OTHER | 000528027001 | 01 | BLUE SHIELD WNY | OTHER | 1612805 | 01 | INDEPENDENT HEALTH | OTHER | 02625074 | 05 | NY | MEDICAID | P00196037 | 01 | RR MEDICARE | OTHER | 000528027005 | 01 | BLUE SHIELD WNY | OTHER | P00209389 | 01 | RR MEDICARE | OTHER | 00027018405 | 01 | UNIVERA | OTHER | 2348183W | 01 | NY | WORKERS COMPENSATION | OTHER | P020234818 | 01 | BLUE SHIELD ROCHESTER | OTHER | 0142859 | 01 | GHI | OTHER | 050901000062 | 01 | FIDELIS | OTHER | 4193669 | 01 | GHI | OTHER | P040234818 | 01 | BLUE SHIELD ROCHESTER | OTHER |