Healthcare Provider Details

I. General information

NPI: 1528062338
Provider Name (Legal Business Name): PAUL WILLIAM HUMPHREY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2005
Last Update Date: 11/22/2021
Certification Date: 11/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3220 BLUFF CREEK DR STE 100
COLUMBIA MO
65201-3525
US

IV. Provider business mailing address

3220 BLUFF CREEK DR SUITE 100
COLUMBIA MO
65201-3525
US

V. Phone/Fax

Practice location:
  • Phone: 573-443-8773
  • Fax: 573-443-6843
Mailing address:
  • Phone: 573-443-8773
  • Fax: 573-443-6843

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberR8N86
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberR8N86
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: