Provider Demographics
NPI:1053480178
Name:HUMPHREY, RANDAL CRAIG (R,CT)
Entity Type:Individual
Prefix:
First Name:RANDAL
Middle Name:CRAIG
Last Name:HUMPHREY
Suffix:
Gender:M
Credentials:R,CT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3026 GUM POND RD
Mailing Address - Street 2:
Mailing Address - City:BAILEYTON
Mailing Address - State:AL
Mailing Address - Zip Code:35019-7014
Mailing Address - Country:US
Mailing Address - Phone:256-350-7779
Mailing Address - Fax:
Practice Address - Street 1:1201 13TH AVE SE
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:AL
Practice Address - Zip Code:35601-4300
Practice Address - Country:US
Practice Address - Phone:256-350-7779
Practice Address - Fax:256-350-2272
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
313224247100000X, 2471C3401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered247100000XTechnologists, Technicians & Other Technical Service ProvidersRadiologic Technologist
Not Answered2471C3401XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistComputed Tomography