Provider Demographics
NPI:1063553980
Name:HUDSON FAMILY PRACTICE, INC
Entity type:Organization
Organization Name:HUDSON FAMILY PRACTICE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:330-344-3000
Mailing Address - Street 1:5655 HUDSON DR
Mailing Address - Street 2:SUITE 303
Mailing Address - City:HUDSON
Mailing Address - State:OH
Mailing Address - Zip Code:44236
Mailing Address - Country:US
Mailing Address - Phone:330-800-4800
Mailing Address - Fax:330-653-3007
Practice Address - Street 1:5655 HUDSON DR
Practice Address - Street 2:SUITE 303
Practice Address - City:HUDSON
Practice Address - State:OH
Practice Address - Zip Code:44236
Practice Address - Country:US
Practice Address - Phone:330-800-4800
Practice Address - Fax:330-653-3007
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-12
Last Update Date:2021-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHCG0422OtherRAILROAD MEDICARE
OH2152790Medicaid
OH9304781Medicare ID - Type Unspecified