Basic Information
| Provider Information | |||||||||
| NPI: | 1639125115 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HOGUE | ||||||||
| FirstName: | GRADY | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2900 E 29TH ST STE 200 | ||||||||
| Address2: | |||||||||
| City: | BRYAN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 778022623 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9794360503 | ||||||||
| FaxNumber: | 9797766905 | ||||||||
| Practice Location | |||||||||
| Address1: | 2900 E 29TH ST STE 200 | ||||||||
| Address2: | |||||||||
| City: | BRYAN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 778022623 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9797768440 | ||||||||
| FaxNumber: | 9797766905 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/26/2006 | ||||||||
| LastUpdateDate: | 10/26/2017 | ||||||||
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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 | 207Q00000X | G8181 | TX | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 8HG239 | 01 | BCBS | OTHER | AETNA | 01 | TX | INDIVIDUAL ID NUMBER | OTHER | 136310314 | 05 | TX | MEDICAID | 136310310 | 05 | TX | MEDICAID |