Provider Demographics
NPI:1770543621
Name:HUMPHREY, ALBERT (MD)
Entity type:Individual
Prefix:DR
First Name:ALBERT
Middle Name:
Last Name:HUMPHREY
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 1:4100 N. MAIN ST
Mailing Address - Street 2:SUITE 203
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29203
Mailing Address - Country:US
Mailing Address - Phone:803-754-0006
Mailing Address - Fax:803-735-1635
Practice Address - Street 1:4100 N. MAIN ST
Practice Address - Street 2:SUITE 203
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203
Practice Address - Country:US
Practice Address - Phone:803-754-0006
Practice Address - Fax:803-735-1635
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-24
Last Update Date:2020-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC8045207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC080450Medicaid
SCGP0304Medicaid
SC080450Medicaid