Healthcare Provider Details

I. General information

NPI: 1154852861
Provider Name (Legal Business Name): STEPHEN M HUDSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/23/2017
Last Update Date: 01/21/2021
Certification Date: 01/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 PRESTIGE PL STE 550
MIAMISBURG OH
45342-6115
US

IV. Provider business mailing address

1 PRESTIGE PL STE 550
MIAMISBURG OH
45342-6115
US

V. Phone/Fax

Practice location:
  • Phone: 859-323-9918
  • Fax: 859-323-1197
Mailing address:
  • Phone: 937-762-1310
  • Fax: 937-522-8068

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number35.139101
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberR4440
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: