Healthcare Provider Details

I. General information

NPI: 1699972893
Provider Name (Legal Business Name): JON O HUMPHREY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2007
Last Update Date: 06/10/2024
Certification Date: 06/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 W JACKSON ST SUITE 200
CARBONDALE IL
62901-1474
US

IV. Provider business mailing address

701 N 1ST ST PO BOX 19639
SPRINGFIELD IL
62794-9639
US

V. Phone/Fax

Practice location:
  • Phone: 618-453-3777
  • Fax: 618-453-1102
Mailing address:
  • Phone: 217-545-7578
  • Fax: 217-545-1884

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number036-116062
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number67471
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: