Provider Demographics
NPI:1679500763
Name:LI, SHENGGANG (MD)
Entity Type:Individual
Prefix:DR
First Name:SHENGGANG
Middle Name:
Last Name:LI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:627 W FOURTH ST
Mailing Address - Street 2:EASTERN STATE HOSPITAL
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40508-1294
Mailing Address - Country:US
Mailing Address - Phone:859-246-7651
Mailing Address - Fax:859-246-7023
Practice Address - Street 1:627 W FOURTH ST
Practice Address - Street 2:EASTERN STATE HOSPITAL
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40508-1294
Practice Address - Country:US
Practice Address - Phone:859-246-7651
Practice Address - Fax:859-246-7023
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY375752084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY37575Medicaid
KY30615058Medicaid
KY0331531Medicare ID - Type UnspecifiedMEDICARE
KY30615058Medicaid
KYH78462Medicare UPIN
KY3341068Medicare ID - Type Unspecified