Individual
MR. BRIAN NEAL SHORE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA C
Contact information
Practice address
2110 FOX DR, CHAMPAIGN, IL 61820-7553
(217) 366-1237
Mailing address
101 W UNIVERSITY AVE, CHAMPAIGN, IL 61820-3909
(217) 366-8107
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
085002428
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
434110
MEDICARE GROUP
IL
01
—
P00382778
RAILROAD MEDICARE
IL
Enumeration date
08/10/2005
Last updated
03/17/2015
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