Basic Information
| Provider Information | |||||||||
| NPI: | 1467822320 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HUMPHREYS | ||||||||
| FirstName: | TARA | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | LAT, ATC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12345 E LEGAL TENDER RD | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 472039424 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8123507495 | ||||||||
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| Practice Location | |||||||||
| Address1: | 275 W BASSETT RD | ||||||||
| Address2: | |||||||||
| City: | SHELBYVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 461768574 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3173922161 | ||||||||
| FaxNumber: | 3173981870 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2015 | ||||||||
| LastUpdateDate: | 10/03/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XX0005X | 36001308A | IN | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine |
No ID Information.