Provider Demographics
NPI:1629019880
Name:SHORE, BERNARD ELLIS (MD)
Entity Type:Individual
Prefix:
First Name:BERNARD
Middle Name:ELLIS
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 1:2021 WINTON ROAD SOUTH
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14618
Mailing Address - Country:US
Mailing Address - Phone:585-427-7760
Mailing Address - Fax:585-427-2193
Practice Address - Street 1:2021 WINTON ROAD SOUTH
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14618
Practice Address - Country:US
Practice Address - Phone:585-427-7760
Practice Address - Fax:585-427-2193
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2008-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1359781207R00000X, 207RG0300X, 207RH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
No207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
B72208Medicare UPIN
NYCC3328Medicare ID - Type Unspecified
A81042Medicare ID - Type Unspecified