MEDICARE: BRETT I. SHORE MD

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	207XX0005X	Sports Medicine (Orthopaedic Surgery) Physician	A120811	CA

General Provider Information

NPI Number	:	1578699989
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRETT I. SHORE MD

Provider Business Mailing Address
First Line	:	2009 FAYMONT AVE
Second Line	:
City	:	MANHATTAN BEACH
State	:	CA
Zip	:	90266-4150
Country	:	US
Telephone Number	:	617-686-7177
Fax Number	:

Provider Business Practice Location Address
First Line	:	4551 GLENCOE AVE STE 145
Second Line	:
City	:	MARINA DEL REY
State	:	CA
Zip	:	90292-6385
Country	:	US
Telephone Number	:	888-778-5000
Fax Number	:

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

Provider Enumeration Date	:	02/27/2007
Last Update Date	:	07/12/2024

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