Provider Demographics
NPI:1447435003
Name:ALBERT HUMPHREY
Entity type:Organization
Organization Name:ALBERT HUMPHREY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ALBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:HUMPHREY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:803-754-0006
Mailing Address - Street 1:4100 MAIN ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29203-5800
Mailing Address - Country:US
Mailing Address - Phone:803-754-0006
Mailing Address - Fax:803-735-1635
Practice Address - Street 1:4100 MAIN ST
Practice Address - Street 2:SUITE 101
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-5800
Practice Address - Country:US
Practice Address - Phone:803-754-0006
Practice Address - Fax:803-735-1635
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-02
Last Update Date:2014-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC8045207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP0304Medicaid
SCD17578Medicare UPIN
SC2049Medicare PIN