Provider Demographics
NPI:1548254220
Name:SHORE, RICHARD M (MD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:M
Last Name:SHORE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:225 E CHICAGO AVE # 9
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-2991
Mailing Address - Country:US
Mailing Address - Phone:312-227-4500
Mailing Address - Fax:312-227-9785
Practice Address - Street 1:225 E CHICAGO AVE # 9
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2991
Practice Address - Country:US
Practice Address - Phone:312-227-4500
Practice Address - Fax:312-227-9785
Is Sole Proprietor?:No
Enumeration Date:2005-09-08
Last Update Date:2019-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-0771752085N0904X, 2085P0229X
IL0360771752085R0202X
IL036.0771752085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear Radiology
No2085P0229XAllopathic & Osteopathic PhysiciansRadiologyPediatric Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036077175Medicaid
ILE19795Medicare UPIN