Provider Demographics
NPI:1548258742
Name:HUDSON, MICHAEL JAMES (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:JAMES
Last Name:HUDSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:710 N NILES AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-1924
Mailing Address - Country:US
Mailing Address - Phone:574-647-1610
Mailing Address - Fax:
Practice Address - Street 1:6913 N MAIN ST
Practice Address - Street 2:
Practice Address - City:GRANGER
Practice Address - State:IN
Practice Address - Zip Code:46530-8039
Practice Address - Country:US
Practice Address - Phone:574-647-1500
Practice Address - Fax:574-243-4343
Is Sole Proprietor?:No
Enumeration Date:2005-10-11
Last Update Date:2016-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01046281A208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200130720Medicaid
IN000000085184OtherBCBS BMG SCHWARTZ
IN000000085183OtherBCBS BMG MAIN STREET
IN000000085182OtherBCBS MEMORIAL CHILDRENS HOSPITAL
IN000000989683OtherBCBS BMG IRELAND RD
IN245510FFMedicare PIN
IN000000085182OtherBCBS MEMORIAL CHILDRENS HOSPITAL
IN000000085184OtherBCBS BMG SCHWARTZ
IN000000085183OtherBCBS BMG MAIN STREET
IN182870CMedicare PIN