Basic Information
| Provider Information | |||||||||
| NPI: | 1669555934 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KURT P HOFMANN MD LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 303 HARRIS INDUSTRIAL BLVD | ||||||||
| Address2: | SUITE 3 | ||||||||
| City: | VIDALIA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 304748850 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8669098354 | ||||||||
| FaxNumber: | 9125380770 | ||||||||
| Practice Location | |||||||||
| Address1: | 303 HARRIS INDUSTRIAL BLVD | ||||||||
| Address2: | SUITE 3 | ||||||||
| City: | VIDALIA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 304748845 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8669098354 | ||||||||
| FaxNumber: | 9125380770 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/23/2006 | ||||||||
| LastUpdateDate: | 06/21/2018 | ||||||||
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| AuthorizedOfficialLastName: | HOFMANN | ||||||||
| AuthorizedOfficialFirstName: | KURT | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 8669098354 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD FACS | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 051197 | GA | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 000945106D | 05 | GA | MEDICAID | 051197 | 01 | GA | LICENSE | OTHER | 341202 | 01 | GA | WELLCARE | OTHER |