Provider Demographics
NPI:1649202268
Name:HUMPHRIES, ROGER L (MD)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:L
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 1:138 LEADER AVE
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40508-3215
Mailing Address - Country:US
Mailing Address - Phone:859-257-7910
Mailing Address - Fax:859-257-7899
Practice Address - Street 1:1000 S LIMESTONE
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40536-0001
Practice Address - Country:US
Practice Address - Phone:859-323-5901
Practice Address - Fax:859-323-3040
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY32479207PE0005X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207PE0005XAllopathic & Osteopathic PhysiciansEmergency MedicineUndersea and Hyperbaric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64324791Medicaid
0508374Medicare ID - Type Unspecified
KY64324791Medicaid