Basic Information
| Provider Information | |||||||||
| NPI: | 1891717815 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHIELDS | ||||||||
| FirstName: | DOUGLAS | ||||||||
| MiddleName: | A. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 98 | ||||||||
| Address2: | |||||||||
| City: | JONAS RIDGE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 286410098 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8283850915 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 125 HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | SPRUCE PINE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 287773035 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8287654201 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/25/2006 | ||||||||
| LastUpdateDate: | 05/02/2012 | ||||||||
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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 | E4736 | TN | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | P00384358 | 01 | KY | MEDICARE RAILROAD | OTHER | 204445209 | 05 | MO | MEDICAID | 5630460000 | 05 | WV | MEDICAID | 010210364 | 05 | VA | MEDICAID | 00125794 | 05 | MS | MEDICAID | 3813512 | 05 | TN | MEDICAID | P0029524 | 01 | WV | MEDICARE RAILROAD | OTHER | 162345001 | 05 | AR | MEDICAID | 3813511 | 05 | TN | MEDICAID | 64338304 | 05 | KY | MEDICAID | 50007474 | 01 | KY | PASSPORT HEALTH | OTHER | P00378743 | 01 | AR | MEDICARE RAILROAD | OTHER |