MEDICARE: WAYNE HUDSON DO INTEGRATED MEDICAL PRACTICE PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	251S00000X	Community/Behavioral Health Agency
2	261QP2300X	Primary Care Clinic/Center
3	261QM1300X	Multi-Specialty Clinic/Center

General Provider Information

NPI Number	:	1093449415
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WAYNE HUDSON DO INTEGRATED MEDICAL PRACTICE PLLC

Provider Business Mailing Address
First Line	:	310 E OLIVE ST
Second Line	:
City	:	LAMAR
State	:	CO
Zip	:	81052-2841
Country	:	US
Telephone Number	:	716-931-9844
Fax Number	:	719-931-8007

Provider Business Practice Location Address
First Line	:	310 E OLIVE ST
Second Line	:
City	:	LAMAR
State	:	CO
Zip	:	81052-2841
Country	:	US
Telephone Number	:	719-691-2291
Fax Number	:

Authorized Official
Title or Position	:	OWNER/PARTNER
Name	:	ROBERT JAY BROOKE
Credential	:	LCSW
Telephone Number	:	719-691-2291

Provider Enumeration Date	:	07/12/2022
Last Update Date	:	12/07/2022

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