Provider Demographics
NPI:1801008073
Name:FREDERIC A. HUMPHREY,D.O.INC.
Entity Type:Organization
Organization Name:FREDERIC A. HUMPHREY,D.O.INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:FREDERIC
Authorized Official - Middle Name:ADAIR
Authorized Official - Last Name:HUMPHREY
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:1740-374-4590
Mailing Address - Street 1:4727 STATE ROUTE 60
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:OH
Mailing Address - Zip Code:45750-5360
Mailing Address - Country:US
Mailing Address - Phone:740-374-4590
Mailing Address - Fax:740-568-0310
Practice Address - Street 1:4727 STATE ROUTE 60
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:OH
Practice Address - Zip Code:45750-5360
Practice Address - Country:US
Practice Address - Phone:740-374-4590
Practice Address - Fax:740-568-0310
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34002561H207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0083356000Medicaid
OH0367802Medicaid
WV0083356000Medicaid
OH0465523Medicare PIN
WV0465522Medicare PIN