Provider Demographics
NPI:1245411891
Name:TOM HUDSON LLC
Entity Type:Organization
Organization Name:TOM HUDSON LLC
Other - Org Name:CONWAY DERMATOLOGY CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:REGINA
Authorized Official - Middle Name:
Authorized Official - Last Name:LAMBERT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-327-8480
Mailing Address - Street 1:9 MEDICAL LANE
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:AR
Mailing Address - Zip Code:72034
Mailing Address - Country:US
Mailing Address - Phone:501-327-8480
Mailing Address - Fax:
Practice Address - Street 1:9 MEDICAL LANE
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72034
Practice Address - Country:US
Practice Address - Phone:501-327-8480
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-23
Last Update Date:2008-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR105042001Medicaid
ARD84169Medicare UPIN
AR105042001Medicaid