Provider Demographics
NPI:1851586192
Name:HUMPHREYS MEDICAL LLC
Entity Type:Organization
Organization Name:HUMPHREYS MEDICAL LLC
Other - Org Name:SHOAL CREEK ORTHOPAEDICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:AARON
Authorized Official - Middle Name:
Authorized Official - Last Name:HUMPHREYS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:217-324-8798
Mailing Address - Street 1:801 E CARPENTER ST
Mailing Address - Street 2:PO BOX 1977
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62702-5323
Mailing Address - Country:US
Mailing Address - Phone:217-544-6464
Mailing Address - Fax:217-757-6021
Practice Address - Street 1:725 SAINT FRANCIS WAY
Practice Address - Street 2:
Practice Address - City:LITCHFIELD
Practice Address - State:IL
Practice Address - Zip Code:62056-1780
Practice Address - Country:US
Practice Address - Phone:217-324-8798
Practice Address - Fax:217-324-8622
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-10
Last Update Date:2008-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0361131128207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
321461OtherPCH GROUP #
321461OtherPCH GROUP #
IL215655Medicare PIN