Provider Demographics
NPI:1215152368
Name:WAYNE R. HUDSON, DO, INC
Entity type:Organization
Organization Name:WAYNE R. HUDSON, DO, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WAYNE
Authorized Official - Middle Name:ROSS
Authorized Official - Last Name:HUDSON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:419-394-4044
Mailing Address - Street 1:1134 HAGER ST
Mailing Address - Street 2:
Mailing Address - City:SAINT MARYS
Mailing Address - State:OH
Mailing Address - Zip Code:45885-2423
Mailing Address - Country:US
Mailing Address - Phone:419-394-4044
Mailing Address - Fax:419-394-1655
Practice Address - Street 1:1134 HAGER ST
Practice Address - Street 2:
Practice Address - City:SAINT MARYS
Practice Address - State:OH
Practice Address - Zip Code:45885-2423
Practice Address - Country:US
Practice Address - Phone:419-394-4044
Practice Address - Fax:419-394-1655
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-16
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH6421208600000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1467436527OtherNPI
OH2002031Medicaid
OH2002031Medicaid
OH9339151Medicare PIN