Provider Demographics
NPI:1255327565
Name:HUMPHRIES, RALEIGH GREEN (MD)
Entity Type:Individual
Prefix:
First Name:RALEIGH
Middle Name:GREEN
Last Name:HUMPHRIES
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 1:200 HAWKINS DR
Mailing Address - Street 2:
Mailing Address - City:IOWA CITY
Mailing Address - State:IA
Mailing Address - Zip Code:52242-1009
Mailing Address - Country:US
Mailing Address - Phone:319-467-2000
Mailing Address - Fax:
Practice Address - Street 1:105 E 9TH ST
Practice Address - Street 2:
Practice Address - City:CORALVILLE
Practice Address - State:IA
Practice Address - Zip Code:52241-2209
Practice Address - Country:US
Practice Address - Phone:319-467-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-22
Last Update Date:2020-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC32117208800000X
IAMD-39882208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8944557Medicaid
NC44557OtherBLUE CROSS BLUE SHIELD
NCB18070Medicare UPIN
VAVVC800AMedicare PIN
NC44557OtherBLUE CROSS BLUE SHIELD
NC207450DMedicare PIN
NC8944557Medicaid
340017970Medicare PIN