Basic Information
| Provider Information | |||||||||
| NPI: | 1851586192 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HUMPHREYS MEDICAL LLC | ||||||||
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| OtherOrganizationName: | SHOAL CREEK ORTHOPAEDICS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 801 E CARPENTER ST | ||||||||
| Address2: | PO BOX 1977 | ||||||||
| City: | SPRINGFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 627025323 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2175446464 | ||||||||
| FaxNumber: | 2177576021 | ||||||||
| Practice Location | |||||||||
| Address1: | 725 SAINT FRANCIS WAY | ||||||||
| Address2: | |||||||||
| City: | LITCHFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620561780 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2173248798 | ||||||||
| FaxNumber: | 2173248622 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/10/2007 | ||||||||
| LastUpdateDate: | 01/22/2008 | ||||||||
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| AuthorizedOfficialLastName: | HUMPHREYS | ||||||||
| AuthorizedOfficialFirstName: | AARON | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2173248798 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 0361131128 | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 321461 | 01 | PCH GROUP # | OTHER |