MEDICARE: MR. GARY D HAYDEN PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant	085001274	IL
2	363A00000X	Physician Assistant	085-001274	IL

General Provider Information

NPI Number	:	1992797625
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. GARY D HAYDEN PA-C

Provider Business Mailing Address
First Line	:	1005 HEALTH CENTER DR STE 201
Second Line	:
City	:	MATTOON
State	:	IL
Zip	:	61938-4693
Country	:	US
Telephone Number	:	217-238-6055
Fax Number	:

Provider Business Practice Location Address
First Line	:	1215 W MAIN ST
Second Line	:
City	:	SHELBYVILLE
State	:	IL
Zip	:	62565-1252
Country	:	US
Telephone Number	:	217-774-4305
Fax Number	:	217-774-4306

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/18/2005
Last Update Date	:	09/24/2018

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