Provider Demographics
NPI:1235138983
Name:SHORE, GREGG IAN (MD)
Entity Type:Individual
Prefix:MR
First Name:GREGG
Middle Name:IAN
Last Name:SHORE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4759 LAKEVIEW DR
Mailing Address - Street 2:STE 101
Mailing Address - City:SEBRING
Mailing Address - State:FL
Mailing Address - Zip Code:33870-2005
Mailing Address - Country:US
Mailing Address - Phone:863-402-5600
Mailing Address - Fax:863-402-5602
Practice Address - Street 1:4759 LAKEVIEW DR
Practice Address - Street 2:STE 101
Practice Address - City:SEBRING
Practice Address - State:FL
Practice Address - Zip Code:33870-2005
Practice Address - Country:US
Practice Address - Phone:863-402-5600
Practice Address - Fax:863-402-5602
Is Sole Proprietor?:No
Enumeration Date:2005-07-15
Last Update Date:2017-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME91364208C00000X, 208600000X
KS0436711208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3710089Medicaid
FLP00603445OtherMEDICARE RAILROAD PROVIDER NUMBER
FL279783600Medicaid
TN3710089Medicare PIN
TN3710089Medicaid
FLU3689YMedicare PIN