Healthcare Provider Details

I. General information

NPI: 1699739599
Provider Name (Legal Business Name): PAUL MICHAEL SHORE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2006
Last Update Date: 01/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3601 A STREET
PHILADELPHIA PA
19134
US

IV. Provider business mailing address

3601 FRONT STREET
PHILADELPHIA PA
19134
US

V. Phone/Fax

Practice location:
  • Phone: 215-427-5000
  • Fax:
Mailing address:
  • Phone: 215-427-5000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License NumberM0273
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License NumberMD070589L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: