Basic Information
| Provider Information | |||||||||
| NPI: | 1750388286 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HODGE | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 950116 | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402950116 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5028930159 | ||||||||
| FaxNumber: | 5022133853 | ||||||||
| Practice Location | |||||||||
| Address1: | 4004 DUPONT CIR | ||||||||
| Address2: | SUITE 220 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402074819 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5028930159 | ||||||||
| FaxNumber: | 5022133853 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2005 | ||||||||
| LastUpdateDate: | 03/05/2018 | ||||||||
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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 | 207Y00000X | 22157 | KY | Y | Allopathic & Osteopathic Physicians | Otolaryngology | 207RX0202X | 22157 | KY | N | Allopathic & Osteopathic Physicians | Internal Medicine | Medical Oncology | 207RX0202X | 01040152A | IN | N | Allopathic & Osteopathic Physicians | Internal Medicine | Medical Oncology | 207Y00000X | 01040152A | IN | N | Allopathic & Osteopathic Physicians | Otolaryngology |
ID Information
| ID | Type | State | Issuer | Description | 040003868 | 01 | KY | MEDICARE RR | OTHER | 64221575 | 05 | KY | MEDICAID |