Basic Information
| Provider Information | |||||||||
| NPI: | 1245441559 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HUDEPOHL | ||||||||
| FirstName: | NATHAN | ||||||||
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| Credential: | MD, MPH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 INDEPENDENCE PT STE 212 | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296154536 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8647976328 | ||||||||
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| Practice Location | |||||||||
| Address1: | 701 GROVE RD FL 1 | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29605 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8644557899 | ||||||||
| FaxNumber: | 8644555474 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2007 | ||||||||
| LastUpdateDate: | 07/15/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 57012072 | OH | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | MD13199 | RI | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 82067 | SC | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 09/28/2010 | 01 | RI | TUFTS HEALTH PLAN | OTHER | 09282010 | 01 | RI | BCBSRI | OTHER | 939025129 | 01 | RI | RI MEDICARE GROUP | OTHER | 08-26-2010 | 01 | RI | NHPRI | OTHER | NH81987 | 05 | RI | MEDICAID | 001772601 | 01 | RI | RI MEDICARE | OTHER | 08-01-2010 | 01 | RI | UNITED HEALTHCARE | OTHER | P00871028 | 01 | RI | RI MEDICARE RR | OTHER | 110086375A | 05 | MA | MEDICAID |