Provider Demographics
NPI:1740877174
Name:HUMPHREYS, WILLIAM T
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:T
Last Name:HUMPHREYS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 COUNTRYSIDE DR
Mailing Address - Street 2:
Mailing Address - City:GREENWICH
Mailing Address - State:OH
Mailing Address - Zip Code:44837-9765
Mailing Address - Country:US
Mailing Address - Phone:216-313-7880
Mailing Address - Fax:
Practice Address - Street 1:5 COUNTRYSIDE DR
Practice Address - Street 2:
Practice Address - City:GREENWICH
Practice Address - State:OH
Practice Address - Zip Code:44837-9765
Practice Address - Country:US
Practice Address - Phone:216-313-7880
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-31
Last Update Date:2020-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3901283251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0309429Medicaid