Provider Demographics
NPI:1043268352
Name:HUMPHREY, KEN ALLEN (MD)
Entity Type:Individual
Prefix:DR
First Name:KEN
Middle Name:ALLEN
Last Name:HUMPHREY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:KEN
Other - Middle Name:ALLEN
Other - Last Name:HUMPHREY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:15 CRANTON WAY #112
Mailing Address - Street 2:SUITE #112
Mailing Address - City:LAKE WYLIE
Mailing Address - State:SC
Mailing Address - Zip Code:29710
Mailing Address - Country:US
Mailing Address - Phone:803-831-7916
Mailing Address - Fax:803-831-7916
Practice Address - Street 1:15 CRANTON WAY #112
Practice Address - Street 2:SUITE #112
Practice Address - City:LAKE WYLIE
Practice Address - State:SC
Practice Address - Zip Code:29710
Practice Address - Country:US
Practice Address - Phone:803-831-7916
Practice Address - Fax:803-831-7916
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2010-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2004-0215207P00000X
CAG40969207Q00000X
SCMD-23075207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G409690Medicaid
SC230752Medicaid
NM93757018Medicaid
NMA48413Medicare UPIN
NM345507302Medicare ID - Type Unspecified
A48413Medicare UPIN
NM93757018Medicaid
SC230752Medicaid