Provider Demographics
NPI:1750388286
Name:HODGE, KENNETH M (MD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:M
Last Name:HODGE
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 1:2944 BRECKENRIDGE LN
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40220-1409
Mailing Address - Country:US
Mailing Address - Phone:502-893-0159
Mailing Address - Fax:502-213-3853
Practice Address - Street 1:2944 BRECKENRIDGE LN
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40220-1409
Practice Address - Country:US
Practice Address - Phone:502-893-0159
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-30
Last Update Date:2022-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01040152A207RX0202X, 207Y00000X
KY22157207RX0202X, 207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64221575Medicaid
KY040003868OtherMEDICARE RR
IN183870BMedicare PIN
KY040003868OtherMEDICARE RR
C69154Medicare UPIN
KY0098604Medicare PIN