Basic Information
| Provider Information | |||||||||
| NPI: | 1568688273 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HUMPERT | ||||||||
| FirstName: | ANDREW | ||||||||
| MiddleName: | DALE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 325 MAINE ST | ||||||||
| Address2: | |||||||||
| City: | LAWRENCE | ||||||||
| State: | KS | ||||||||
| PostalCode: | 660441360 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7855056100 | ||||||||
| FaxNumber: | 7855052874 | ||||||||
| Practice Location | |||||||||
| Address1: | 325 MAINE ST | ||||||||
| Address2: | |||||||||
| City: | LAWRENCE | ||||||||
| State: | KS | ||||||||
| PostalCode: | 66044 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7855056100 | ||||||||
| FaxNumber: | 7855052874 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/18/2007 | ||||||||
| LastUpdateDate: | 12/01/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/01/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 04-35452 | KS | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208000000X | 04-35452 | KS | N | Allopathic & Osteopathic Physicians | Pediatrics | 208M00000X | 0435452 | KS | Y | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 200750400A | 05 | KS | MEDICAID |