1356489652 NPI number — SHAWN GORDEN MD PSC

Table of content: (NPI 1356489652)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356489652 NPI number — SHAWN GORDEN MD PSC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SHAWN GORDEN MD PSC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1356489652
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/26/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
617 23RD ST
Provider Second Line Business Mailing Address:
STE 6
Provider Business Mailing Address City Name:
ASHLAND
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
41101-2845
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
606-326-0024
Provider Business Mailing Address Fax Number:
606-326-0041

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
617 23RD ST
Provider Second Line Business Practice Location Address:
STE 6
Provider Business Practice Location Address City Name:
ASHLAND
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
41101-2845
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-326-0024
Provider Business Practice Location Address Fax Number:
606-326-0041
Provider Enumeration Date:
02/01/2007

Additional Information

Authorized Official

Authorized Official Last Name:
GORDEN
Authorized Official First Name:
SHAWN
Authorized Official Middle Name:
Authorized Official Title or Position:
PRES
Authorized Official Telephone Number:
606-326-0024

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  39057 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 64091820 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com