1295962751 NPI number — GARY SHORE MD PC

Table of content: (NPI 1295962751)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295962751 NPI number — GARY SHORE MD PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GARY SHORE MD PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1295962751
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/20/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
87 E LEXINGTON AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OCEANSIDE
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11572-5420
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
516-377-2820
Provider Business Mailing Address Fax Number:
516-378-2968

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
31 MERRICK AVE
Provider Second Line Business Practice Location Address:
SUITE 230
Provider Business Practice Location Address City Name:
MERRICK
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11566-3477
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
516-377-2820
Provider Business Practice Location Address Fax Number:
516-378-2968
Provider Enumeration Date:
06/11/2009

Additional Information

Authorized Official

Authorized Official Last Name:
SHORE
Authorized Official First Name:
GARY
Authorized Official Middle Name:
J
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
516-377-2820

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  179490 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: DP304 . This is a "OXFORD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 179491N01 . This is a "HIP" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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