Basic Information
| Provider Information | |||||||||
| NPI: | 1225056922 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HUMPHREY | ||||||||
| FirstName: | PETER | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 GEORGE ST | ||||||||
| Address2: | FL 6 | ||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065116624 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037856610 | ||||||||
| FaxNumber: | 2037856414 | ||||||||
| Practice Location | |||||||||
| Address1: | 216 S KINGSHIGHWAY BLVD | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631101026 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3143625641 | ||||||||
| FaxNumber: | 3143620369 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2006 | ||||||||
| LastUpdateDate: | 11/29/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0101X | 100219 | MO | Y | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology |
ID Information
| ID | Type | State | Issuer | Description | 023010176 | 05 | MO | MEDICAID |