Provider Demographics
NPI:1588081566
Name:SHAW, GREGORY EDWARD
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:EDWARD
Last Name:SHAW
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 776879
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6879
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:100 MALLARD CREEK RD STE 395
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-5167
Practice Address - Country:US
Practice Address - Phone:502-895-9421
Practice Address - Fax:502-899-5762
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-27
Last Update Date:2022-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY50503208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100488410Medicaid
KYK246121OtherMEDICARE
IN300011149Medicaid