Provider Demographics
NPI:1568481315
Name:PHILIP S SHORE M D INC
Entity type:Organization
Organization Name:PHILIP S SHORE M D INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:S
Authorized Official - Last Name:SHORE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-886-1100
Mailing Address - Street 1:18546 ROSCOE BLVD
Mailing Address - Street 2:SUITE 302
Mailing Address - City:NORTHRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:91324-4663
Mailing Address - Country:US
Mailing Address - Phone:818-886-1100
Mailing Address - Fax:818-886-7501
Practice Address - Street 1:18546 ROSCOE BLVD
Practice Address - Street 2:SUITE 302
Practice Address - City:NORTHRIDGE
Practice Address - State:CA
Practice Address - Zip Code:91324-4663
Practice Address - Country:US
Practice Address - Phone:818-886-1100
Practice Address - Fax:818-886-7501
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PHILIP S. SHORE, M.D. INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-19
Last Update Date:2015-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG071824207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G718240OtherBLUE SHIELD
CAW16958Medicare ID - Type Unspecified
CAW17192Medicare UPIN