Basic Information
Provider Information | |||||||||
NPI: | 1851482947 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GORDEN | ||||||||
FirstName: | SHAWN | ||||||||
MiddleName: | R | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 509 MEMORIAL DR STE 2 | ||||||||
Address2: |   | ||||||||
City: | MANCHESTER | ||||||||
State: | KY | ||||||||
PostalCode: | 409626196 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6065985104 | ||||||||
FaxNumber: | 6065980983 | ||||||||
Practice Location | |||||||||
Address1: | 56 MARIE LANGDON DR | ||||||||
Address2: |   | ||||||||
City: | MANCHESTER | ||||||||
State: | KY | ||||||||
PostalCode: | 409626329 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6065994080 | ||||||||
FaxNumber: | 6065981688 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/27/2006 | ||||||||
LastUpdateDate: | 03/18/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | L3666 | TX | N |   | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |   | 207V00000X | 39057 | KY | Y |   | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |   |
ID Information
ID | Type | State | Issuer | Description | FG6575712 | 01 | KY | DEA | OTHER | 2552545 | 05 | OH |   | MEDICAID | 64091820 | 05 | KY |   | MEDICAID | 11356327 | 01 |   | CAQH ID | OTHER | 215019501 | 05 | TX |   | MEDICAID |