=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356489652
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SHAWN GORDEN MD PSC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/01/2007
-----------------------------------------------------
Last Update Date | 06/26/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 617 23RD ST STE 6
-----------------------------------------------------
City | ASHLAND
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 41101-2845
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 606-326-0024
-----------------------------------------------------
Fax | 606-326-0041
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 617 23RD ST STE 6
-----------------------------------------------------
City | ASHLAND
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 41101-2845
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 606-326-0024
-----------------------------------------------------
Fax | 606-326-0041
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRES
-----------------------------------------------------
Name | DR. SHAWN GORDEN
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 606-326-0024
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 39057
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------