Provider Demographics
NPI:1366448599
Name:GAUGHAN, ELLEN CELESTE (MD)
Entity Type:Individual
Prefix:DR
First Name:ELLEN
Middle Name:CELESTE
Last Name:GAUGHAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:159 MARGARET STREET
Mailing Address - Street 2:SUITE 500
Mailing Address - City:PLATTSBURGH
Mailing Address - State:NY
Mailing Address - Zip Code:12901-1874
Mailing Address - Country:US
Mailing Address - Phone:518-566-8603
Mailing Address - Fax:518-566-8582
Practice Address - Street 1:159 MARGARET STREET
Practice Address - Street 2:SUITE 500
Practice Address - City:PLATTSBURGH
Practice Address - State:NY
Practice Address - Zip Code:12901-1874
Practice Address - Country:US
Practice Address - Phone:518-566-8603
Practice Address - Fax:518-566-8582
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-22
Last Update Date:2014-11-03
Deactivation Date:2006-03-15
Deactivation Code:
Reactivation Date:2006-03-27
Provider Licenses
StateLicense IDTaxonomies
NY2133082084N0400X, 208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY000495471003OtherBLUE SHIELD OF NENY
NYP010213308OtherBC OF UTICA WATERTOWN
NY01998998Medicaid
NY130023170OtherRAILROAD MEDICARE
NY141826450OtherTRICARE
NY8C1231OtherBLUE CROSS BLUE SHIELD
NY141826450OtherUNITED HEALTHCARE
NY110639300OtherUS DEPT OF LABOR
NY698338OtherMVP
NY01998998Medicaid