Basic Information
| Provider Information | |||||||||
| NPI: | 1235305566 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHORE | ||||||||
| FirstName: | AMY | ||||||||
| MiddleName: | WALL | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WALL | ||||||||
| OtherFirstName: | AMY | ||||||||
| OtherMiddleName: | SUZANNE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 4148 | ||||||||
| Address2: | |||||||||
| City: | TORRANCE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 905104148 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3107923914 | ||||||||
| FaxNumber: | 8558984055 | ||||||||
| Practice Location | |||||||||
| Address1: | 3445 PCH HWY STE 110 | ||||||||
| Address2: | |||||||||
| City: | TORRANCE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 905056659 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6176862647 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/06/2008 | ||||||||
| LastUpdateDate: | 12/12/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 226228 | MA | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207L00000X | 30993 | AL | Y | Allopathic & Osteopathic Physicians | Anesthesiology | 207L00000X | A123437 | CA | N | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 132224 | 05 | AL | MEDICAID | 132231 | 05 | AL | MEDICAID | 051120731 | 01 | AL | BCBS | OTHER | 132222 | 05 | AL | MEDICAID | 051120732 | 01 | AL | BCBS | OTHER | 051120734 | 01 | AL | BCBS | OTHER | 051120729 | 01 | AL | BCBS | OTHER | 132226 | 05 | AL | MEDICAID | 01600227 | 05 | MS | MEDICAID |