Individual
MARY ELLEN THERESA SHIELDS
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
M.D.
Contact information
Practice address
305 ESTILL ST, BEREA, KY 40403-1742
(859) 986-8418
(859) 986-6568
Mailing address
PO BOX 936, LONDON, KY 40743-0936
(859) 986-8418
(859) 986-6568
Taxonomy
Speciality
Code
Description
License number
State
208600000X
Surgery Physician
Primary
30354
KY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
64303548
—
KY
01
—
P00357584
RRMC
KY
Enumeration date
05/26/2006
Last updated
05/05/2022
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