Provider Demographics
NPI:1144289448
Name:SHADOWEN, MICHAEL W (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:W
Last Name:SHADOWEN
Suffix:
Gender:M
Credentials:MD
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 1537
Mailing Address - Street 2:
Mailing Address - City:GLASGOW
Mailing Address - State:KY
Mailing Address - Zip Code:42142-1537
Mailing Address - Country:US
Mailing Address - Phone:270-651-9129
Mailing Address - Fax:270-651-4916
Practice Address - Street 1:106 E WAYNE ST
Practice Address - Street 2:
Practice Address - City:GLASGOW
Practice Address - State:KY
Practice Address - Zip Code:42141-2636
Practice Address - Country:US
Practice Address - Phone:270-651-9129
Practice Address - Fax:270-651-4916
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2016-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY214732085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64214737Medicaid
KY000000057712OtherANTHEM
KYC64970Medicare UPIN
KY64214737Medicaid