Provider Demographics
NPI:1659710440
Name:HODGES, BLAKE M (MD)
Entity Type:Individual
Prefix:
First Name:BLAKE
Middle Name:M
Last Name:HODGES
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 968
Mailing Address - Street 2:
Mailing Address - City:ABBEVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29620-0968
Mailing Address - Country:US
Mailing Address - Phone:864-366-5011
Mailing Address - Fax:
Practice Address - Street 1:901 W GREENWOOD ST STE 1
Practice Address - Street 2:
Practice Address - City:ABBEVILLE
Practice Address - State:SC
Practice Address - Zip Code:29620-5727
Practice Address - Country:US
Practice Address - Phone:864-366-9681
Practice Address - Fax:864-366-5600
Is Sole Proprietor?:No
Enumeration Date:2013-06-14
Last Update Date:2023-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC35680207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC423971OtherMEDICARE GROUP PTAN
SC3255OtherMEDICARE PTAN
SCRHC210OtherGROUP MEDICAID
SC356803Medicaid