Provider Demographics
NPI:1528062338
Name:HUMPHREY, PAUL WILLIAM (MD)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:WILLIAM
Last Name:HUMPHREY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3220 BLUFF CREEK DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65201-3525
Mailing Address - Country:US
Mailing Address - Phone:573-443-8773
Mailing Address - Fax:573-443-6843
Practice Address - Street 1:3220 BLUFF CREEK DR
Practice Address - Street 2:STE 100
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-3525
Practice Address - Country:US
Practice Address - Phone:573-443-8773
Practice Address - Fax:573-443-6843
Is Sole Proprietor?:No
Enumeration Date:2005-06-09
Last Update Date:2021-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR8N86208600000X, 2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO28058OtherGHP
MO4343322OtherAETNA
MO18421OtherANTHEM BLUECROSS BLUESHIE
MO431428562OtherGREAT WEST
MO342470OtherPHCS
MO223429OtherHEALTHLINK, INC
MO3476OtherHEALTHCARE USA
MO1284581OtherUNITED HEALTHCARE
MO203559109Medicaid
MOF37040OtherMERCY
MO000000171Medicare PIN
MOF37040OtherMERCY
MO1284581OtherUNITED HEALTHCARE
MO4343322OtherAETNA