MEDICARE: SAMUEL MARK SHOR M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	101036333	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	504468	OTHER	VA	NCPPO PROVIDER NUMBER
2	745990	OTHER	VA	CIGNA PROVIDER NUMBER

General Provider Information

NPI Number	:	1184611964
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SAMUEL MARK SHOR M.D.

Provider Business Mailing Address
First Line	:	1860 TOWN CENTER DR
Second Line	:	SUITE 230
City	:	RESTON
State	:	VA
Zip	:	20190-5896
Country	:	US
Telephone Number	:	703-709-1119
Fax Number	:	703-709-7496

Provider Business Practice Location Address
First Line	:	1860 TOWN CENTER DR
Second Line	:	SUITE 230
City	:	RESTON
State	:	VA
Zip	:	20190-5896
Country	:	US
Telephone Number	:	703-709-1119
Fax Number	:	703-709-7496

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/05/2005
Last Update Date	:	01/05/2012

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