Provider Demographics
NPI:1043665532
Name:SHAW FAMILY MEDICAL, LLC
Entity Type:Organization
Organization Name:SHAW FAMILY MEDICAL, LLC
Other - Org Name:GOUGH'S FAMILY MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NORA
Authorized Official - Middle Name:
Authorized Official - Last Name:GOUGH-DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:662-745-6638
Mailing Address - Street 1:PO BOX 68
Mailing Address - Street 2:
Mailing Address - City:DREW
Mailing Address - State:MS
Mailing Address - Zip Code:38737-0068
Mailing Address - Country:US
Mailing Address - Phone:662-745-6638
Mailing Address - Fax:662-745-8480
Practice Address - Street 1:189 N MAIN ST
Practice Address - Street 2:
Practice Address - City:DREW
Practice Address - State:MS
Practice Address - Zip Code:38737-3146
Practice Address - Country:US
Practice Address - Phone:662-745-6638
Practice Address - Fax:662-745-8480
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SHAW FAMILY MEDICAL, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-05-03
Last Update Date:2016-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR872155363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS04406222Medicaid
MS04406222Medicaid