Healthcare Provider Details

I. General information

NPI: 1790784106
Provider Name (Legal Business Name): JAMES W SHORE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2005
Last Update Date: 05/26/2021
Certification Date: 05/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

117 KENNEDY DR
MARTIN TN
38237-3394
US

IV. Provider business mailing address

117 KENNEDY DR
MARTIN TN
38237-3309
US

V. Phone/Fax

Practice location:
  • Phone: 731-587-9511
  • Fax: 877-309-6416
Mailing address:
  • Phone: 731-587-9511
  • Fax: 877-309-6416

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD5113
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: