Healthcare Provider Details

I. General information

NPI: 1578632006
Provider Name (Legal Business Name): ROBERT W HODGE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2006
Last Update Date: 04/23/2024
Certification Date: 04/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6411 VETERANS MEMORIAL PARKWAY
CREESTWOOD KY
40014-8611
US

IV. Provider business mailing address

PO BOX 776351
CHICAGO IL
60677-6351
US

V. Phone/Fax

Practice location:
  • Phone: 502-241-8611
  • Fax: 502-241-4175
Mailing address:
  • Phone: 502-588-9490
  • Fax: 502-272-5114

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number18819
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: