Provider Demographics
NPI:1912903857
Name:SHORES, ANNETTE V (MD)
Entity type:Individual
Prefix:
First Name:ANNETTE
Middle Name:V
Last Name:SHORES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 GOOD SAMARITAN WAY
Mailing Address - Street 2:SUITE 235
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62864-2408
Mailing Address - Country:US
Mailing Address - Phone:618-899-3980
Mailing Address - Fax:618-899-4793
Practice Address - Street 1:2 GOOD SAMARITAN WAY
Practice Address - Street 2:SUITE 235
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-2408
Practice Address - Country:US
Practice Address - Phone:618-899-3980
Practice Address - Fax:618-899-4793
Is Sole Proprietor?:No
Enumeration Date:2005-06-24
Last Update Date:2014-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036093049208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036093049Medicaid
IL036093049Medicaid
IL916920Medicare ID - Type Unspecified
ILK35379Medicare PIN