Provider Demographics
NPI:1699739599
Name:SHORE, PAUL MICHAEL (MD)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:MICHAEL
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 1:3601 FRONT STREET
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19134
Mailing Address - Country:US
Mailing Address - Phone:215-427-5000
Mailing Address - Fax:
Practice Address - Street 1:3601 A STREET
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19134
Practice Address - Country:US
Practice Address - Phone:215-427-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-17
Last Update Date:2014-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM02732080P0203X
PAMD070589L2080P0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX170113801Medicaid
TX8C9839Medicare ID - Type Unspecified
TX170113801Medicaid