Provider Demographics
NPI:1427053347
Name:SHORE, BRADLEY SCOTT (MD)
Entity type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:SCOTT
Last Name:SHORE
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 1:11995 SINGLETREE LN
Mailing Address - Street 2:SUITE 500
Mailing Address - City:EDEN PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55344-5347
Mailing Address - Country:US
Mailing Address - Phone:952-595-1100
Mailing Address - Fax:952-942-3361
Practice Address - Street 1:4901 WILLS ST
Practice Address - Street 2:
Practice Address - City:METAIRIE
Practice Address - State:LA
Practice Address - Zip Code:70006-1132
Practice Address - Country:US
Practice Address - Phone:952-595-1100
Practice Address - Fax:952-942-3361
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2011-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA0223722085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102090529Medicaid
LA1948063Medicaid
LA1481823Medicaid
LA5A589DD19Medicare PIN
G70291Medicare UPIN
LA1481823Medicaid
LA5F993Medicare ID - Type Unspecified