Healthcare Provider Details

I. General information

NPI: 1912903857
Provider Name (Legal Business Name): ANNETTE V SHORES M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2005
Last Update Date: 01/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 GOOD SAMARITAN WAY SUITE 235
MOUNT VERNON IL
62864-2408
US

IV. Provider business mailing address

2 GOOD SAMARITAN WAY SUITE 235
MOUNT VERNON IL
62864-2408
US

V. Phone/Fax

Practice location:
  • Phone: 618-899-3980
  • Fax: 618-899-4793
Mailing address:
  • Phone: 618-899-3980
  • Fax: 618-899-4793

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number036093049
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: