Healthcare Provider Details

I. General information

NPI: 1609857358
Provider Name (Legal Business Name): FREDERICK WILLIAM HODGE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/09/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11616 CHAPMAN HWY
SEYMOUR TN
37865-5046
US

IV. Provider business mailing address

11616 CHAPMAN HWY
SEYMOUR TN
37865-5046
US

V. Phone/Fax

Practice location:
  • Phone: 865-579-3720
  • Fax: 865-577-7309
Mailing address:
  • Phone: 865-579-3720
  • Fax: 865-577-7309

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD0000004935
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: