Healthcare Provider Details

I. General information

NPI: 1932302668
Provider Name (Legal Business Name): KELLY L HODGES MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2007
Last Update Date: 10/05/2020
Certification Date: 10/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9000 W WISCONSIN AVE DIVISION OF CHILD PROTECTION
MILWAUKEE WI
53226-4874
US

IV. Provider business mailing address

9000 W WISCONSIN AVE DIVISION OF CHILD PROTECTION
MILWAUKEE WI
53226-4874
US

V. Phone/Fax

Practice location:
  • Phone: 414-277-8980
  • Fax: 414-277-8969
Mailing address:
  • Phone: 414-277-8980
  • Fax: 414-277-8969

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number52848-20
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code2080C0008X
TaxonomyChild Abuse Pediatrics Physician
License Number52848
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: