Provider Demographics
NPI:1376312074
Name:SHORE ORTHOPEDICS A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:SHORE ORTHOPEDICS A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRETT
Authorized Official - Middle Name:
Authorized Official - Last Name:SHORE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:617-686-7177
Mailing Address - Street 1:2009 FAYMONT AVE
Mailing Address - Street 2:
Mailing Address - City:MANHATTAN BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90266-4150
Mailing Address - Country:US
Mailing Address - Phone:617-686-7177
Mailing Address - Fax:
Practice Address - Street 1:4551 GLENCOE AVE STE 145
Practice Address - Street 2:
Practice Address - City:MARINA DEL REY
Practice Address - State:CA
Practice Address - Zip Code:90292-6385
Practice Address - Country:US
Practice Address - Phone:949-988-7800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-12-22
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Single Specialty
No261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical SpecialtyGroup - Single Specialty