Provider Demographics
NPI:1215578471
Name:HUMPHREY, EDWARD L
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:L
Last Name:HUMPHREY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2519 8TH ST NW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44708-4373
Mailing Address - Country:US
Mailing Address - Phone:330-285-8415
Mailing Address - Fax:
Practice Address - Street 1:380 S PORTAGE PATH
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44320-2326
Practice Address - Country:US
Practice Address - Phone:330-315-4917
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-30
Last Update Date:2019-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker