Provider Demographics
NPI:1043244684
Name:HUMPHREY, WILLIAM MERRITT (MD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:MERRITT
Last Name:HUMPHREY
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 1:315 N. WASHINGTON AVENUE, SUITE 103
Mailing Address - Street 2:
Mailing Address - City:COOKEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38501
Mailing Address - Country:US
Mailing Address - Phone:931-528-2443
Mailing Address - Fax:931-528-1488
Practice Address - Street 1:315 N. WASHINGTON AVENUE, SUITE 103
Practice Address - Street 2:
Practice Address - City:COOKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:38501
Practice Address - Country:US
Practice Address - Phone:931-528-2443
Practice Address - Fax:931-528-1488
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2016-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD062782085R0202X
TN6278208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3193466Medicaid
TN3193466Medicaid
TN3193465Medicare ID - Type Unspecified