Provider Demographics
NPI:1578632006
Name:HODGE, ROBERT W (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:W
Last Name:HODGE
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 776351
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6351
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5114
Practice Address - Street 1:6411 VETERANS MEMORIAL PARKWAY
Practice Address - Street 2:
Practice Address - City:CREESTWOOD
Practice Address - State:KY
Practice Address - Zip Code:40014-8611
Practice Address - Country:US
Practice Address - Phone:502-241-8611
Practice Address - Fax:502-241-4175
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2021-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY18819207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYP00736602OtherRMEDICARE/NCMA
KY64188196OtherMEDICAID/NCMA
50021271OtherPASSPORT/NCMA MIDD
50021974OtherPASSPORT/NCMAPEWEE
KY64188196Medicaid
KY00533118OtherKYMEDICARE-NCMA
099096OtherSIHO/NCMA
KYP00736602OtherRMEDICARE/NCMA
KYC71277Medicare UPIN
0257915Medicare ID - Type Unspecified