Provider Demographics
NPI:1609981752
Name:HUDSON, RICKEY HUGH SR (MD)
Entity Type:Individual
Prefix:DR
First Name:RICKEY
Middle Name:HUGH
Last Name:HUDSON
Suffix:SR
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:P.O. BOX 30384
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38130-0384
Mailing Address - Country:US
Mailing Address - Phone:901-332-5873
Mailing Address - Fax:901-332-6084
Practice Address - Street 1:4299 ELVIS PRESLEY BLVD.
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38116-6084
Practice Address - Country:US
Practice Address - Phone:901-332-5873
Practice Address - Fax:901-332-6084
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-20
Last Update Date:2010-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN018656207Q00000X
TNMD016565207QA0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0000XAllopathic & Osteopathic PhysiciansFamily MedicineAdolescent Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0165491OtherBLUE CROSS BLUE SHEILD
TN116899Medicaid
TN0165491Medicaid
TN3032169Medicaid
TN3032169Medicare UPIN
TN116899Medicaid
TN3032169Medicare ID - Type Unspecified