Basic Information
| Provider Information | |||||||||
| NPI: | 1235138819 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HUMPHREY | ||||||||
| FirstName: | STEPHEN | ||||||||
| MiddleName: | HARMES | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1655 BERNARDIN AVE | ||||||||
| Address2: | SUITE 220 | ||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292042039 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8032545038 | ||||||||
| FaxNumber: | 8033765883 | ||||||||
| Practice Location | |||||||||
| Address1: | 1655 BERNARDIN AVE | ||||||||
| Address2: | SUITE 220 | ||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292042039 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8032545038 | ||||||||
| FaxNumber: | 8033765883 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 11061 | SC | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 110616 | 05 | SC | MEDICAID |