Provider Demographics
NPI:1104852029
Name:HUDSON, JAMES WALLACE (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:WALLACE
Last Name:HUDSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:429 ROPER MOUNTAIN RD STE 700
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-4261
Mailing Address - Country:US
Mailing Address - Phone:864-412-2777
Mailing Address - Fax:855-877-7043
Practice Address - Street 1:429 ROPER MOUNTAIN RD STE 700
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-4261
Practice Address - Country:US
Practice Address - Phone:864-412-2777
Practice Address - Fax:855-877-7043
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2020-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC20424207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC204246Medicaid
SC204246Medicaid
SCG89726Medicare UPIN
SCP00664049OtherRR MEDICARE
SCG89726Medicare UPIN
SCP00664049OtherRR MEDICARE