Basic Information
| Provider Information | |||||||||
| NPI: | 1720227721 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHIELDS | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | L. | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SHIELDS | ||||||||
| OtherFirstName: | CHARLES | ||||||||
| OtherMiddleName: | L. | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1045 S GUM SPRINGS RD | ||||||||
| Address2: | |||||||||
| City: | PADUCAH | ||||||||
| State: | KY | ||||||||
| PostalCode: | 420019299 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2705546656 | ||||||||
| FaxNumber: | 2704414370 | ||||||||
| Practice Location | |||||||||
| Address1: | 1045 S GUM SPRINGS RD | ||||||||
| Address2: | |||||||||
| City: | PADUCAH | ||||||||
| State: | KY | ||||||||
| PostalCode: | 420019299 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2705546656 | ||||||||
| FaxNumber: | 2704414370 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/13/2009 | ||||||||
| LastUpdateDate: | 02/13/2009 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 15548 | KY | Y | Other Service Providers | Specialist |
No ID Information.