Provider Demographics
NPI:1356489652
Name:SHAWN GORDEN MD PSC
Entity Type:Organization
Organization Name:SHAWN GORDEN MD PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRES
Authorized Official - Prefix:DR
Authorized Official - First Name:SHAWN
Authorized Official - Middle Name:
Authorized Official - Last Name:GORDEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:606-326-0024
Mailing Address - Street 1:617 23RD ST
Mailing Address - Street 2:STE 6
Mailing Address - City:ASHLAND
Mailing Address - State:KY
Mailing Address - Zip Code:41101-2845
Mailing Address - Country:US
Mailing Address - Phone:606-326-0024
Mailing Address - Fax:606-326-0041
Practice Address - Street 1:617 23RD ST
Practice Address - Street 2:STE 6
Practice Address - City:ASHLAND
Practice Address - State:KY
Practice Address - Zip Code:41101-2845
Practice Address - Country:US
Practice Address - Phone:606-326-0024
Practice Address - Fax:606-326-0041
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-01
Last Update Date:2008-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY39057174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64091820Medicaid
KY0941701Medicare PIN
KYH71312Medicare UPIN