Healthcare Provider Details

I. General information

NPI: 1245234277
Provider Name (Legal Business Name): GREGORY HUDSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2005
Last Update Date: 02/22/2021
Certification Date: 02/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

137 STATE ROUTE 3117
SOUTH SHORE KY
41175-9597
US

IV. Provider business mailing address

137 STATE ROUTE 3117
SOUTH SHORE KY
41175-9597
US

V. Phone/Fax

Practice location:
  • Phone: 606-932-2079
  • Fax: 606-932-2313
Mailing address:
  • Phone: 606-932-2079
  • Fax: 606-932-2313

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number35061298
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number25242
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: