Provider Demographics
NPI:1578744181
Name:HUDSON DERMATOLOGY, PC
Entity Type:Organization
Organization Name:HUDSON DERMATOLOGY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:P
Authorized Official - Last Name:HUDSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:812-474-1234
Mailing Address - Street 1:3501 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47714-0538
Mailing Address - Country:US
Mailing Address - Phone:812-474-1234
Mailing Address - Fax:812-402-3636
Practice Address - Street 1:3501 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47714-0538
Practice Address - Country:US
Practice Address - Phone:812-474-1234
Practice Address - Fax:812-402-3636
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-26
Last Update Date:2008-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01029475A174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000079535OtherANTHEM
INP00134400OtherRR MEDICARE
IN0000000317128OtherANTHEM BCBS
IN1023595OtherTRICARE
IN693560Medicare PIN
IN000000079535OtherANTHEM