Basic Information
| Provider Information | |||||||||
| NPI: | 1841262052 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HUMPHREY | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1272 GARRISON DR | ||||||||
| Address2: | |||||||||
| City: | MURFREESBORO | ||||||||
| State: | TN | ||||||||
| PostalCode: | 371292598 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6158934480 | ||||||||
| FaxNumber: | 6158677951 | ||||||||
| Practice Location | |||||||||
| Address1: | 1272 GARRISON DR | ||||||||
| Address2: | |||||||||
| City: | MURFREESBORO | ||||||||
| State: | TN | ||||||||
| PostalCode: | 371292598 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6158934480 | ||||||||
| FaxNumber: | 6158677951 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/02/2006 | ||||||||
| LastUpdateDate: | 04/09/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | MD21354 | TN | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 3065243 | 05 | TN | MEDICAID |