Healthcare Provider Details

I. General information

NPI: 1548009723
Provider Name (Legal Business Name): JEROD HUDSON
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/20/2024
Last Update Date: 04/01/2026
Certification Date: 04/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9320 US HIGHWAY 301 S
RIVERVIEW FL
33578
US

IV. Provider business mailing address

9320 US HIGHWAY 301 S
RIVERVIEW FL
33578
US

V. Phone/Fax

Practice location:
  • Phone: 813-471-0000
  • Fax: 656-233-5024
Mailing address:
  • Phone: 813-471-0000
  • Fax: 656-233-5024

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number9553955
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAPRN11040199
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: