Basic Information
| Provider Information | |||||||||
| NPI: | 1316130560 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HODGES SURGICAL CLINIC, P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2854 HIGHWAY 55 | ||||||||
| Address2: | SUITE #130 | ||||||||
| City: | EAGAN | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551212156 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6518423329 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2854 HIGHWAY 55 | ||||||||
| Address2: | SUITE #130 | ||||||||
| City: | EAGAN | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551212156 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6518423329 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/21/2007 | ||||||||
| LastUpdateDate: | 08/30/2007 | ||||||||
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| AuthorizedOfficialLastName: | HODGES | ||||||||
| AuthorizedOfficialFirstName: | LEROY | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6512244930 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | 129703 | 01 | MN | HEALTH PARTNERS | OTHER |