Basic Information
| Provider Information | |||||||||
| NPI: | 1760412373 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HODGES | ||||||||
| FirstName: | KEVIN | ||||||||
| MiddleName: | ERIC | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 505 S 336TH ST | ||||||||
| Address2: | SUITE 600 | ||||||||
| City: | FEDERAL WAY | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980036328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2538386180 | ||||||||
| FaxNumber: | 2538386418 | ||||||||
| Practice Location | |||||||||
| Address1: | 888 SWIFT BLVD | ||||||||
| Address2: | |||||||||
| City: | RICHLAND | ||||||||
| State: | WA | ||||||||
| PostalCode: | 993523514 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5099464611 | ||||||||
| FaxNumber: | 5099422757 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/03/2006 | ||||||||
| LastUpdateDate: | 05/23/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | MD00046333 | WA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3075HO | 01 | WA | BSWA | OTHER | 3735HO | 01 | WA | BSWA | OTHER | 0216263 | 01 | WA | LIWA | OTHER | 8462681 | 05 | WA | MEDICAID |