Provider Demographics
NPI:1609002518
Name:SAMUEL L HUDSON MDPA
Entity Type:Organization
Organization Name:SAMUEL L HUDSON MDPA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CAMILLE
Authorized Official - Middle Name:
Authorized Official - Last Name:HUDSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:979-299-6900
Mailing Address - Street 1:PO BOX 4165
Mailing Address - Street 2:
Mailing Address - City:LAKE JACKSON
Mailing Address - State:TX
Mailing Address - Zip Code:77566-2065
Mailing Address - Country:US
Mailing Address - Phone:979-299-6900
Mailing Address - Fax:979-299-6903
Practice Address - Street 1:120 FLAG LAKE DR
Practice Address - Street 2:
Practice Address - City:LAKE JACKSON
Practice Address - State:TX
Practice Address - Zip Code:77566-6292
Practice Address - Country:US
Practice Address - Phone:979-299-6900
Practice Address - Fax:979-299-6903
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-05
Last Update Date:2009-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF4099332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX183692601Medicaid
TX00W884Medicare PIN
TXC17162Medicare UPIN
TX183692601Medicaid