Provider Demographics
NPI:1447297155
Name:HUDSON-KANE, CARMELITA M (MD)
Entity type:Individual
Prefix:
First Name:CARMELITA
Middle Name:M
Last Name:HUDSON-KANE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:609 NORTHDALE DR
Mailing Address - Street 2:
Mailing Address - City:PERRYVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63775-1115
Mailing Address - Country:US
Mailing Address - Phone:573-517-0036
Mailing Address - Fax:
Practice Address - Street 1:465 S MOUNT AUBURN RD
Practice Address - Street 2:SUITE 103
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63703-4926
Practice Address - Country:US
Practice Address - Phone:573-335-2900
Practice Address - Fax:573-335-2905
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2012-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOMD101365207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
110212243OtherMEDICARE RAILROAD
F31392Medicare UPIN