MEDICARE: HUDSON DERMATOLOGY, PC

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	174400000X	Specialist	01029475A	IN

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	P00134400	OTHER	IN	RR MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000000079535	OTHER	IN	ANTHEM
3	0000000317128	OTHER	IN	ANTHEM BCBS
4	1023595	OTHER	IN	TRICARE

General Provider Information

NPI Number	:	1578744181
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HUDSON DERMATOLOGY, PC

Provider Business Mailing Address
First Line	:	3501 WASHINGTON AVE
Second Line	:
City	:	EVANSVILLE
State	:	IN
Zip	:	47714-0538
Country	:	US
Telephone Number	:	812-474-1234
Fax Number	:	812-402-3636

Provider Business Practice Location Address
First Line	:	3501 WASHINGTON AVE
Second Line	:
City	:	EVANSVILLE
State	:	IN
Zip	:	47714-0538
Country	:	US
Telephone Number	:	812-474-1234
Fax Number	:	812-402-3636

Authorized Official
Title or Position	:	OWNER
Name	:	DR. CHARLES P HUDSON
Credential	:
Telephone Number	:	812-474-1234

Provider Enumeration Date	:	11/26/2007
Last Update Date	:	02/27/2008

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Directions to “HUDSON DERMATOLOGY, PC ” Practice Location

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