1669490736 NPI number — JIM KYLE HUDSON III M.D.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669490736 NPI number — JIM KYLE HUDSON III M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HUDSON
Provider First Name:
JIM
Provider Middle Name:
KYLE
Provider Name Prefix Text:
Provider Name Suffix Text:
III
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1669490736
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/29/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6077 PRIMACY PKWY STE 140
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MEMPHIS
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
38119-5742
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
901-725-8347
Provider Business Mailing Address Fax Number:
901-259-7637

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6029 WALNUT GROVE RD STE 403
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MEMPHIS
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38120-2112
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
901-261-7836
Provider Business Practice Location Address Fax Number:
901-226-0215
Provider Enumeration Date:
07/17/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X , with the licence number:  09724 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: T08483A . This is a "MEDICARE" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 793967 . This is a "MEDICARE" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: 00123456 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1522223 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".