Provider Demographics
NPI:1881852317
Name:SHEA GODWIN MD PSC
Entity Type:Organization
Organization Name:SHEA GODWIN MD PSC
Other - Org Name:GODWIN FAMILY PRACTICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHEA
Authorized Official - Middle Name:A
Authorized Official - Last Name:GODWIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:270-522-6963
Mailing Address - Street 1:250 MAIN ST
Mailing Address - Street 2:SUITE E
Mailing Address - City:CADIZ
Mailing Address - State:KY
Mailing Address - Zip Code:42211-9153
Mailing Address - Country:US
Mailing Address - Phone:270-522-6963
Mailing Address - Fax:270-522-7231
Practice Address - Street 1:250 MAIN ST
Practice Address - Street 2:SUITE E
Practice Address - City:CADIZ
Practice Address - State:KY
Practice Address - Zip Code:42211-9153
Practice Address - Country:US
Practice Address - Phone:270-522-6963
Practice Address - Fax:270-522-7231
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-31
Last Update Date:2008-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1538257910OtherPROVIDER NPI
KY1096567OtherUSA MANAGED CARE ORGANIZATION