Healthcare Provider Details

I. General information

NPI: 1649459322
Provider Name (Legal Business Name): RONALD SHORE MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/30/2007
Last Update Date: 04/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4701 RANDOLPH RD STE 207
ROCKVILLE MD
20852-2261
US

IV. Provider business mailing address

4701 RANDOLPH RD STE 207
ROCKVILLE MD
20852-2261
US

V. Phone/Fax

Practice location:
  • Phone: 410-872-9188
  • Fax: 410-872-9169
Mailing address:
  • Phone: 410-872-9188
  • Fax: 410-872-9169

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number StateMD

VIII. Authorized Official

Name: MR. DAVID M FISH
Title or Position: VP BILLING
Credential:
Phone: 410-872-9188