Provider Demographics
NPI:1730165366
Name:SHILT, JEFFREY S (MD)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:S
Last Name:SHILT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:208-381-2222
Mailing Address - Fax:
Practice Address - Street 1:703 S AMERICANA BLVD
Practice Address - Street 2:STE 120
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-5099
Practice Address - Country:US
Practice Address - Phone:208-323-2600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-15
Last Update Date:2014-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9901473207X00000X
IDM10261207XP3100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XP3100XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryPediatric Orthopaedic Surgery
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
200043936OtherRR MEDICARE
200043936OtherRR MEDICARE