1992774640 NPI number — MRS. SHANNON CHRISTINE HUDSON IDC

Table of content: MRS. SHANNON CHRISTINE HUDSON IDC (NPI 1992774640)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992774640 NPI number — MRS. SHANNON CHRISTINE HUDSON IDC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HUDSON
Provider First Name:
SHANNON
Provider Middle Name:
CHRISTINE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
IDC
Provider Gender Code:
F

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:
1992774640
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/20/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2534 GUM WAY
Provider Second Line Business Mailing Address:
APT C
Provider Business Mailing Address City Name:
LEXINGTON PARK
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
20653-2288
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
301-342-1429
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
47149 BUSE RD
Provider Second Line Business Practice Location Address:
UNIT #1370
Provider Business Practice Location Address City Name:
PATUXENT RIVER
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
20670-1540
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-342-1429
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/15/2006

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: 1710I1002X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1710I1002X . This is a "INDEPENDENT DUTY CORPSMAN" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".




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