Provider Demographics
NPI:1821050006
Name:SHUBE, PRISCILLA (MD)
Entity Type:Individual
Prefix:
First Name:PRISCILLA
Middle Name:
Last Name:SHUBE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 MILL RD
Mailing Address - Street 2:STE 180
Mailing Address - City:FAIRHAVEN
Mailing Address - State:MA
Mailing Address - Zip Code:02719-5252
Mailing Address - Country:US
Mailing Address - Phone:508-973-2000
Mailing Address - Fax:508-973-2001
Practice Address - Street 1:479 SWANSEA MALL DR
Practice Address - Street 2:
Practice Address - City:SWANSEA
Practice Address - State:MA
Practice Address - Zip Code:02777-4119
Practice Address - Country:US
Practice Address - Phone:508-973-1570
Practice Address - Fax:508-973-1545
Is Sole Proprietor?:No
Enumeration Date:2006-04-04
Last Update Date:2020-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA60124207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110046540AMedicaid
MA110046540AMedicaid
MAM20518Medicare PIN
MAJ12031Medicare ID - Type Unspecified
MAJ1203101Medicare PIN