Provider Demographics
NPI:1245221233
Name:HUDGINS, MARIANNE B (MD)
Entity Type:Individual
Prefix:
First Name:MARIANNE
Middle Name:B
Last Name:HUDGINS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARIANNE
Other - Middle Name:
Other - Last Name:BLACKMON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:12639 OLD TESSON RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63128-2786
Mailing Address - Country:US
Mailing Address - Phone:816-363-4100
Mailing Address - Fax:816-363-8201
Practice Address - Street 1:6420 PROSPECT AVENUE
Practice Address - Street 2:SUITE T101
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64132-1186
Practice Address - Country:US
Practice Address - Phone:816-363-4100
Practice Address - Fax:816-363-8201
Is Sole Proprietor?:No
Enumeration Date:2005-10-31
Last Update Date:2016-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO114452207R00000X
KS04-26395207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO209006808Medicaid
MOG70851Medicare UPIN
MO5238405Medicare ID - Type UnspecifiedMEDICARE - MO AND KS