Provider Demographics
NPI:1245441559
Name:HUDEPOHL, NATHAN (MD, MPH)
Entity type:Individual
Prefix:
First Name:NATHAN
Middle Name:
Last Name:HUDEPOHL
Suffix:
Gender:M
Credentials:MD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 INDEPENDENCE PT STE 212
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-4536
Mailing Address - Country:US
Mailing Address - Phone:864-797-6328
Mailing Address - Fax:
Practice Address - Street 1:701 GROVE RD FL 1
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605
Practice Address - Country:US
Practice Address - Phone:864-455-7899
Practice Address - Fax:864-455-5474
Is Sole Proprietor?:No
Enumeration Date:2007-05-25
Last Update Date:2019-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH57012072207P00000X
RIMD13199207P00000X
SC82067207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI09/28/2010OtherTUFTS HEALTH PLAN
RI09282010OtherBCBSRI
RI939025129OtherRI MEDICARE GROUP
RI08-26-2010OtherNHPRI
RINH81987Medicaid
RI001772601OtherRI MEDICARE
RI08-01-2010OtherUNITED HEALTHCARE
RIP00871028OtherRI MEDICARE RR
MA110086375AMedicaid