Healthcare Provider Details

I. General information

NPI: 1649202268
Provider Name (Legal Business Name): ROGER L HUMPHRIES MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2006
Last Update Date: 02/07/2024
Certification Date: 02/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 S LIMESTONE
LEXINGTON KY
40536-0001
US

IV. Provider business mailing address

138 LEADER AVE
LEXINGTON KY
40508-3215
US

V. Phone/Fax

Practice location:
  • Phone: 859-323-5901
  • Fax: 859-323-3040
Mailing address:
  • Phone: 859-257-7910
  • Fax: 859-257-7899

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number32479
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code207PE0005X
TaxonomyUndersea and Hyperbaric Medicine (Emergency Medicine) Physician
License Number32479
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: