1164733697 NPI number — MR. THOMAS RANDALL HUMPHREY PA

Table of content: MR. THOMAS RANDALL HUMPHREY PA (NPI 1164733697)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164733697 NPI number — MR. THOMAS RANDALL HUMPHREY PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HUMPHREY
Provider First Name:
THOMAS
Provider Middle Name:
RANDALL
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
PA
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1164733697
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/20/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1930 BRANNAN RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MCDONOUGH
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30253-4310
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
678-284-4040
Provider Business Mailing Address Fax Number:
678-284-4076

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1357 HEMBREE RD
Provider Second Line Business Practice Location Address:
SUITE 250
Provider Business Practice Location Address City Name:
ROSWELL
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30076-5722
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-475-7550
Provider Business Practice Location Address Fax Number:
770-343-9080
Provider Enumeration Date:
06/30/2010

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  001599 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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