Basic Information
| Provider Information | |||||||||
| NPI: | 1902900061 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SUSAN B HUMPHREYS MD PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 148 CRESTVIEW DR | ||||||||
| Address2: | |||||||||
| City: | ABINGDON | ||||||||
| State: | VA | ||||||||
| PostalCode: | 242102010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2765237943 | ||||||||
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| Practice Location | |||||||||
| Address1: | CARROLL & TATE STREETS | ||||||||
| Address2: | |||||||||
| City: | LEBANON | ||||||||
| State: | VA | ||||||||
| PostalCode: | 24266 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2765237943 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/11/2006 | ||||||||
| LastUpdateDate: | 10/25/2007 | ||||||||
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| AuthorizedOfficialLastName: | HUMPHREYS | ||||||||
| AuthorizedOfficialFirstName: | SUSAN | ||||||||
| AuthorizedOfficialMiddleName: | B. | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2765237943 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 0101038126 | VA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 236019 | 01 | VA | ANTHEM BCBS | OTHER | DD2295 | 01 | VA | RR MEDICARE | OTHER |