MEDICARE: KIMBERLY K HUDSPETH M.D.

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	0431810	KS
2	208M00000X	Hospitalist Physician	036131870	IL
3	208M00000X	Hospitalist Physician	04-31810	KS
4	207R00000X	Internal Medicine Physician	036131870	IL

General Provider Information

NPI Number	:	1518079623
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KIMBERLY K HUDSPETH M.D.

Provider Business Mailing Address
First Line	:	9515 HOLY CROSS LN
Second Line	:
City	:	BREESE
State	:	IL
Zip	:	62230-3618
Country	:	US
Telephone Number	:	618-526-4511
Fax Number	:	618-526-4537

Provider Business Practice Location Address
First Line	:	205 MUNSTER ST
Second Line	:
City	:	GERMANTOWN
State	:	IL
Zip	:	62245-1004
Country	:	US
Telephone Number	:	618-523-4216
Fax Number	:	618-523-7049

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/31/2006
Last Update Date	:	11/07/2018

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