=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154852861
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STEPHEN M HUDSON M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/23/2017
-----------------------------------------------------
Last Update Date | 01/21/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1 PRESTIGE PL STE 550
-----------------------------------------------------
City | MIAMISBURG
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45342-6115
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 859-323-9918
-----------------------------------------------------
Fax | 859-323-1197
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1 PRESTIGE PL STE 550
-----------------------------------------------------
City | MIAMISBURG
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45342-6115
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-762-1310
-----------------------------------------------------
Fax | 937-522-8068
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 35.139101
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | R4440
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------