=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902900061
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SUSAN B HUMPHREYS MD PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/11/2006
-----------------------------------------------------
Last Update Date | 10/25/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | CARROLL & TATE STREETS
-----------------------------------------------------
City | LEBANON
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24266
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 276-523-7943
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 148 CRESTVIEW DR
-----------------------------------------------------
City | ABINGDON
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24210-2010
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 276-523-7943
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | SUSAN B. HUMPHREYS
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 276-523-7943
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number | 0101038126
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------