Provider Demographics
NPI:1639164528
Name:HUMENIUK, JOHN MICHAEL (MD, LLC)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:MICHAEL
Last Name:HUMENIUK
Suffix:
Gender:M
Credentials:MD, LLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 MEMORIAL MEDICAL DR
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29605-4407
Mailing Address - Country:US
Mailing Address - Phone:864-295-9085
Mailing Address - Fax:864-295-1075
Practice Address - Street 1:21 MEMORIAL MEDICAL DR
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605-4407
Practice Address - Country:US
Practice Address - Phone:864-295-9085
Practice Address - Fax:864-295-1075
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-16
Last Update Date:2013-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC10819207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC108190Medicaid
B917000281Medicare ID - Type Unspecified
SCB917000281Medicare PIN
B91700Medicare UPIN