Basic Information
| Provider Information | |||||||||
| NPI: | 1487650404 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHORE | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 3720 FARRAGUT AVE | ||||||||
| Address2: | STE 103 | ||||||||
| City: | KENSINGTON | ||||||||
| State: | MD | ||||||||
| PostalCode: | 208952110 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3019348811 | ||||||||
| FaxNumber: | 3019349321 | ||||||||
| Practice Location | |||||||||
| Address1: | 3720 FARRAGUT AVE | ||||||||
| Address2: | STE 103 | ||||||||
| City: | KENSINGTON | ||||||||
| State: | MD | ||||||||
| PostalCode: | 208952110 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3019348811 | ||||||||
| FaxNumber: | 3019349321 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2005 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 2282 | MD | Y | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 001089 | 01 | MD | VALUE OPTIONS | OTHER | H1630001 | 01 | DC | BLUE CROSS | OTHER | 412350 | 01 | MD | MAMSI/ALLIANCE | OTHER | 2282 | 01 | MD | KAISER | OTHER | 254102500 | 05 | MD | MEDICAID | 458821000 | 01 | MD | MAGELLAN | OTHER | 52475204 | 01 | MD | BLUE CROSS | OTHER |