Shaw Family Medical, LLC
Organization Active NPI Family Nurse Practitioner · Drew, MS
NPI 1043665532 · NPPES record last updated May 3, 2016
Key facts
- NPI
- 1043665532
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Family Nurse Practitioner 363LF0000X
- License
- R872155 (MS)
- Legal business name
- SHAW FAMILY MEDICAL, LLC
- Practice address
- 189 N Main St
Drew, MS 38737-3146 - Phone
- (662) 745-6638
- Fax
- (662) 745-8480
- NPI assigned
- May 3, 2016
- Organization subpart
- Yes
- Parent organization (as reported)
- SHAW FAMILY MEDICAL, LLC
Authorized official
- Name
- Nora Gough-Davis, FNP
- Title
- Owner
- Phone
- (662) 745-6638
Parent organization (reported in NPPES) 1
Other NPIs on the same Medicare enrollment 1
Corporate family (same tax ID) 1
Practitioners 14
-
Meta H Anderson, FNP-C
-
Regina Jonelle Evans, FNP
-
Queeneice Boyette Ganison, FNP-BC
-
Vanessa Haywood, FNP
-
Sharron Shonet Moore, FNP-BC
-
Natayla Potts, FNP
-
Sereka V Walker, FNP-BC
-
Tomeka Wright-Little, NURSE PRACTITIONER
-
Lamonica Antonette Hodges, FNP-C
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in MS
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20120809000742 | MS | Part B Supplier - Clinic/Group Practice | 3072769843 |
Receives reassigned benefits from 12 practitioners 1 other NPI on this enrollment This NPI is an additional NPI on the enrollment Practice locations: Drew, MS; Shaw, MS |
National Provider Directory
- Tax ID family
- Shaw Family Medical
- Part of
- Shaw Family Medical
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Family Nurse Practitioner |
363LF0000X | R872155 | MS | Yes |
Addresses
Primary practice location
189 N Main St
Drew, MS 38737-3146
Mailing address
PO Box 68
Drew, MS 38737-0068
Phone (662) 745-6638
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 04406222 | Medicaid | MS |
Other names
- Gough's Family Medical Clinic
Other providers in Drew, MS
- Monette Hospice, Incorporated
- North Delta Adult Daycare of Drew Inc.
- Scallion Family Medical Clinic LLC
- Brooke Scallion
- Serene Hospice Group
- Evelyn Smith
- Jeri L. Thompson
All providers in Drew, MS · Family Nurse Practitioner in Mississippi
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on May 3, 2016. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.