Provider Demographics
NPI:1669806055
Name:BLACKMORE, SHANE ANTHONY (MD)
Entity type:Individual
Prefix:DR
First Name:SHANE
Middle Name:ANTHONY
Last Name:BLACKMORE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:2 COOPER SQ
Mailing Address - Street 2:9C
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10003-7153
Mailing Address - Country:US
Mailing Address - Phone:347-463-3405
Mailing Address - Fax:
Practice Address - Street 1:301 E 17TH ST
Practice Address - Street 2:ROOM 1402
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10003-3804
Practice Address - Country:US
Practice Address - Phone:212-598-6509
Practice Address - Fax:212-598-7654
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-21
Last Update Date:2013-08-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NYP89608207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine