Provider Demographics
NPI:1295962751
Name:GARY SHORE MD PC
Entity type:Organization
Organization Name:GARY SHORE MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:J
Authorized Official - Last Name:SHORE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:516-377-2820
Mailing Address - Street 1:87 E LEXINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11572-5420
Mailing Address - Country:US
Mailing Address - Phone:516-377-2820
Mailing Address - Fax:516-378-2968
Practice Address - Street 1:31 MERRICK AVE
Practice Address - Street 2:SUITE 230
Practice Address - City:MERRICK
Practice Address - State:NY
Practice Address - Zip Code:11566-3477
Practice Address - Country:US
Practice Address - Phone:516-377-2820
Practice Address - Fax:516-378-2968
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-11
Last Update Date:2010-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY179490207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DP304OtherOXFORD
NY179491N01OtherHIP
NYF34254Medicare UPIN