Basic Information
| Provider Information | |||||||||
| NPI: | 1235113325 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HUDSON | ||||||||
| FirstName: | REX | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4853 | ||||||||
| Address2: | DEPT 4036 | ||||||||
| City: | OAK BROOK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605224853 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6307340200 | ||||||||
| FaxNumber: | 6307341560 | ||||||||
| Practice Location | |||||||||
| Address1: | 12303 DE PAUL DR | ||||||||
| Address2: | DEPAUL HEALTH CENTER | ||||||||
| City: | BRIDGETON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630442512 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3143446000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/01/2005 | ||||||||
| LastUpdateDate: | 12/10/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 2003002294 | MO | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 208801407 | 05 | MO | MEDICAID |