NPIMap

Organization Active NPI

Shaw Family Medical, LLC

Doing business as Gough's Family Medical Clinic

  • Family Nurse Practitioner
  • Drew, MS
National Provider Identifier
1043665532
Registry record updated May 3, 2016
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Nurse PractitionerTaxonomy code 363LF0000X
License
R872155 Issued in MS
Legal business name
SHAW FAMILY MEDICAL, LLC
Doing business as
Gough's Family Medical Clinic
Practice address
189 N Main St
Drew, MS 38737-3146
Phone
(662) 745-6638
Fax
(662) 745-8480
NPI assigned
May 3, 2016
Last updated
May 3, 2016By the provider in NPPES
Organization subpart
Yes
Parent organization
SHAW FAMILY MEDICAL, LLCAs reported in NPPES

NPPES NPI Registry

Updated by the provider on May 3, 2016

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Nora Gough-Davis, FNPNPI 1740410661
Title
Owner
Phone
(662) 745-6638

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Family Nurse Practitioner 363LF0000X R872155 MS Primary

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 1

IdentifierTypeStateIssuer
04406222MedicaidMS

Other names 1

  • Gough's Family Medical Clinic Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MS

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
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

Other NPIs on the same Medicare enrollment 1

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

National Provider Directory

National Provider Directory
Tax ID family
Shaw Family Medical2 organizations share this tax ID, including this one
Part of
Shaw Family Medical

Other organizations with this tax ID 1

Organizations that report the same tax identification number in the National Provider Directory.

Ownership & related parties

Parent organization (reported in NPPES) 1

This organization reports itself as a subpart in NPPES; the parent’s legal name matches this organization in the same state.

Practitioners & affiliated clinicians

Practitioners 14

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 14

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1462233600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1462233600000",
    "number": "1043665532",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 68",
            "city": "DREW",
            "state": "MS",
            "postal_code": "387370068",
            "telephone_number": "662-745-6638",
            "fax_number": "662-745-8480"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "189 N MAIN ST",
            "city": "DREW",
            "state": "MS",
            "postal_code": "387373146",
            "telephone_number": "662-745-6638",
            "fax_number": "662-745-8480"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SHAW FAMILY MEDICAL, LLC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "SHAW FAMILY MEDICAL, LLC",
        "enumeration_date": "2016-05-03",
        "last_updated": "2016-05-03",
        "status": "A",
        "authorized_official_last_name": "GOUGH-DAVIS",
        "authorized_official_first_name": "NORA",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "662-745-6638",
        "authorized_official_credential": "FNP"
    },
    "taxonomies": [
        {
            "code": "363LF0000X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Family",
            "state": "MS",
            "license": "R872155",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "04406222",
            "state": "MS"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Gough's Family Medical Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Drew, MS

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 3, 2016; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.