Basic Information
| Provider Information | |||||||||
| NPI: | 1386733731 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HUMPHREY | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12200 W 106TH ST | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | OVERLAND PARK | ||||||||
| State: | KS | ||||||||
| PostalCode: | 662152305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9135418897 | ||||||||
| FaxNumber: | 9135419135 | ||||||||
| Practice Location | |||||||||
| Address1: | 12200 W 106TH ST | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | OVERLAND PARK | ||||||||
| State: | KS | ||||||||
| PostalCode: | 662152305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9135418897 | ||||||||
| FaxNumber: | 9135419135 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2006 | ||||||||
| LastUpdateDate: | 02/09/2022 | ||||||||
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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 | 207X00000X | 0421147 | KS | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 100114030B | 05 | KS | MEDICAID | 15113011 | 01 | KC | OTHER | 1386733731 | 05 | MO | MEDICAID | 100114030A | 05 | KS | MEDICAID |