Basic Information
| Provider Information | |||||||||
| NPI: | 1255599007 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HODGE | ||||||||
| FirstName: | MARGIE | ||||||||
| MiddleName: | M. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KENNEN | ||||||||
| OtherFirstName: | MARGIE | ||||||||
| OtherMiddleName: | M. | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PA-C | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 232 CHANCERY RD | ||||||||
| Address2: | |||||||||
| City: | WHEELING | ||||||||
| State: | WV | ||||||||
| PostalCode: | 260031760 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3049056995 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 90 N 4TH ST | ||||||||
| Address2: | |||||||||
| City: | MARTINS FERRY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 439351648 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7406334544 | ||||||||
| FaxNumber: | 7406334493 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/29/2008 | ||||||||
| LastUpdateDate: | 05/13/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/13/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | MA053370 | PA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AM0700X | 01279 | WV | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363AM0700X | 50.002109 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 0077638 | 05 | OH | MEDICAID |