Healthcare Provider Details

I. General information

NPI: 1760409577
Provider Name (Legal Business Name): JAY A HUDSON M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/16/2006
Last Update Date: 09/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3366 OAKDALE AVE N SUITE 605
ROBBINSDALE MN
55422-2948
US

IV. Provider business mailing address

3366 OAKDALE AVE N SUITE 605
ROBBINSDALE MN
55422-2948
US

V. Phone/Fax

Practice location:
  • Phone: 763-520-2940
  • Fax: 763-520-2943
Mailing address:
  • Phone: 763-520-2940
  • Fax: 763-520-2943

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number36568
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number36568
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: