Basic Information
| Provider Information | |||||||||
| NPI: | 1700863438 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HUDSON | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | KENNISON | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | |||||||||
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| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 3696 WHEELER RD | ||||||||
| Address2: | |||||||||
| City: | AUGUSTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 309096520 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7067361830 | ||||||||
| FaxNumber: | 7067375103 | ||||||||
| Practice Location | |||||||||
| Address1: | 3696 WHEELER RD | ||||||||
| Address2: | |||||||||
| City: | AUGUSTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 309096520 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7067361830 | ||||||||
| FaxNumber: | 7067375103 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/23/2005 | ||||||||
| LastUpdateDate: | 08/09/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 041582 | GA | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 00723874 | 05 | GA | MEDICAID | G41582 | 05 | SC | MEDICAID | P00035369 | 01 | GA | RAILROAD MEDICARE | OTHER | 3600044 | 01 | GA | UNITED HEALTHCARE | OTHER | 2126300 | 01 | GA | AETNA | OTHER | 717228 | 01 | GA | BLUE CROSS BLUE SHIELD | OTHER |