Basic Information
Provider Information | |||||||||
NPI: | 1548576549 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HODGE | ||||||||
FirstName: | KATHERINE | ||||||||
MiddleName: | J | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | D.O. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | CASSITY | ||||||||
OtherFirstName: | KATHERINE | ||||||||
OtherMiddleName: | J | ||||||||
OtherNamePrefix: | MISS | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 3889 | ||||||||
Address2: |   | ||||||||
City: | JOHNSON CITY | ||||||||
State: | TN | ||||||||
PostalCode: | 376023889 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4234336625 | ||||||||
FaxNumber: | 4232839480 | ||||||||
Practice Location | |||||||||
Address1: | 301 MED TECH PKWY STE 240 | ||||||||
Address2: |   | ||||||||
City: | JOHNSON CITY | ||||||||
State: | TN | ||||||||
PostalCode: | 376042641 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4237945520 | ||||||||
FaxNumber: | 4232826940 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/27/2010 | ||||||||
LastUpdateDate: | 06/08/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/08/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 58-003548 | OH | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207R00000X | 0102203947 | VA | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207R00000X | 2704 | TN | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 1548576549 | 05 | VA |   | MEDICAID | 7100307000 | 05 | KY |   | MEDICAID | Q006172 | 05 | TN |   | MEDICAID | 1548576549 | 05 | NC |   | MEDICAID |