Provider Demographics
NPI:1568410553
Name:HUSSONG, RICHARD L JR
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:L
Last Name:HUSSONG
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 HOSPITAL CENTER COMMON
Mailing Address - Street 2:SUITE 100
Mailing Address - City:HILTON HEAD
Mailing Address - State:SC
Mailing Address - Zip Code:29926
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:25 HOSPITAL CENTER COMMON
Practice Address - Street 2:SUITE 100
Practice Address - City:HILTON HEAD
Practice Address - State:SC
Practice Address - Zip Code:29926
Practice Address - Country:US
Practice Address - Phone:843-681-9489
Practice Address - Fax:843-681-4502
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2008-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC23407208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC234071Medicaid
SCG74881Medicare UPIN
SCG748816892Medicare ID - Type Unspecified