Healthcare Provider Details

I. General information

NPI: 1497803514
Provider Name (Legal Business Name): MATTHEW SHORE D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/08/2007
Last Update Date: 04/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8380 OLD YORK RD STE 100
ELKINS PARK PA
19027-1574
US

IV. Provider business mailing address

PO BOX 820933
PHILADELPHIA PA
19182-0933
US

V. Phone/Fax

Practice location:
  • Phone: 215-517-5000
  • Fax: 215-517-5829
Mailing address:
  • Phone: 215-926-9010
  • Fax: 215-226-8285

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOS007633L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: