Healthcare Provider Details

I. General information

NPI: 1992027213
Provider Name (Legal Business Name): BENJAMIN JOEL SHORE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/01/2010
Last Update Date: 02/09/2021
Certification Date: 02/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 LONGWOOD AVE DEPARTMENT OF ORTHOPEDIC SURGERY - HUNNEWELL 221
BOSTON MA
02115-5724
US

IV. Provider business mailing address

300 LONGWOOD AVE DEPARTMENT OF ORTHOPEDIC SURGERY - HUNNEWELL 221
BOSTON MA
02115-5724
US

V. Phone/Fax

Practice location:
  • Phone: 617-355-6808
  • Fax: 617-730-0465
Mailing address:
  • Phone: 617-355-6808
  • Fax: 617-730-0465

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberMD24223
License Number StateME
# 2
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number243828
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: