Provider Demographics
NPI:1295744134
Name:HUMPHREYS, ROBERT ALAN (MD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:ALAN
Last Name:HUMPHREYS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:965 RIDGE LAKE BLVD
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38120-9401
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:901-227-8591
Practice Address - Street 1:6685 POPLAR AVE STE 120
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:TN
Practice Address - Zip Code:38138-3742
Practice Address - Country:US
Practice Address - Phone:901-685-8245
Practice Address - Fax:901-685-8248
Is Sole Proprietor?:No
Enumeration Date:2006-08-07
Last Update Date:2021-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN9953207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4052782OtherBLUE CROSS BLUE SHIELD
TN103I089735Medicare PIN
TN4052782OtherBLUE CROSS BLUE SHIELD
TN3171680Medicare ID - Type Unspecified
B03484Medicare UPIN