Provider Demographics
NPI:1407851348
Name:HUMPHRIES, MARION KEMPER III (MD)
Entity Type:Individual
Prefix:
First Name:MARION
Middle Name:KEMPER
Last Name:HUMPHRIES
Suffix:III
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:PO BOX 1789
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24008-1789
Mailing Address - Country:US
Mailing Address - Phone:540-855-5100
Mailing Address - Fax:
Practice Address - Street 1:707 S JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24016-5100
Practice Address - Country:US
Practice Address - Phone:540-855-5100
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101017954174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAB06148Medicare UPIN