MEDICARE: SAMUEL DAVID HUDSON MD

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	208000000X	Pediatrics Physician	56722	KY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1912560202
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SAMUEL DAVID HUDSON MD

Provider Business Mailing Address
First Line	:	137 STATE ROUTE 3117
Second Line	:
City	:	SOUTH SHORE
State	:	KY
Zip	:	41175-9597
Country	:	US
Telephone Number	:	606-932-2079
Fax Number	:	606-932-2313

Provider Business Practice Location Address
First Line	:	137 STATE ROUTE 3117
Second Line	:
City	:	SOUTH SHORE
State	:	KY
Zip	:	41175-9597
Country	:	US
Telephone Number	:	606-932-2079
Fax Number	:	606-932-2313

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

Provider Enumeration Date	:	04/22/2019
Last Update Date	:	06/22/2022

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