Healthcare Provider Details

I. General information

NPI: 1023046034
Provider Name (Legal Business Name): BRIDGET HUMPHRIES MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2006
Last Update Date: 12/01/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1650 COWLES ST
FAIRBANKS AK
99701-5907
US

IV. Provider business mailing address

1954 E FORT UNION BLVD #116
SALT LAKE CITY UT
84121-6800
US

V. Phone/Fax

Practice location:
  • Phone: 800-945-9877
  • Fax:
Mailing address:
  • Phone: 907-452-2700
  • Fax: 801-733-5618

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number5753
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: