Provider Demographics
NPI:1194738419
Name:HUMPHRIES, ELLEN C (MD)
Entity type:Individual
Prefix:DR
First Name:ELLEN
Middle Name:C
Last Name:HUMPHRIES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:ELLEN
Other - Middle Name:H
Other - Last Name:CHARTOCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:FIFTEEN MEDICAL PARK
Mailing Address - Street 2:SUITE 300
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29203
Mailing Address - Country:US
Mailing Address - Phone:803-434-7950
Mailing Address - Fax:803-255-3451
Practice Address - Street 1:FIFTEEN MEDICAL PARK
Practice Address - Street 2:SUITE 300
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203
Practice Address - Country:US
Practice Address - Phone:803-434-7950
Practice Address - Fax:803-255-3451
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCTL28945208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAB75110Medicare UPIN