Provider Demographics
NPI:1417943937
Name:HODGSON, KIM J (MD)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:J
Last Name:HODGSON
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:PO BOX 19638
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62794-9638
Mailing Address - Country:US
Mailing Address - Phone:217-545-5555
Mailing Address - Fax:217-545-2563
Practice Address - Street 1:340 W MILLER ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702-4928
Practice Address - Country:US
Practice Address - Phone:217-545-5555
Practice Address - Fax:217-545-2563
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2014-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360727942086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036072794Medicaid
IL256510Medicare PIN
ILL60184Medicare PIN
C43767Medicare UPIN