Provider Demographics
NPI:1285680553
Name:SHIELDS, MARY ELLEN THERESA (MD)
Entity type:Individual
Prefix:
First Name:MARY ELLEN
Middle Name:THERESA
Last Name:SHIELDS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 936
Mailing Address - Street 2:
Mailing Address - City:LONDON
Mailing Address - State:KY
Mailing Address - Zip Code:40743-0936
Mailing Address - Country:US
Mailing Address - Phone:859-986-8418
Mailing Address - Fax:859-986-6568
Practice Address - Street 1:305 ESTILL ST
Practice Address - Street 2:
Practice Address - City:BEREA
Practice Address - State:KY
Practice Address - Zip Code:40403-1742
Practice Address - Country:US
Practice Address - Phone:859-986-8418
Practice Address - Fax:859-986-6568
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-26
Last Update Date:2022-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY30354208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64303548Medicaid
KYP00357584OtherRRMC
KYT54587Medicare UPIN
KY64303548Medicaid