Provider Demographics
NPI:1962623546
Name:HUMPHREY, LISA (MD)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:HUMPHREY
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 CHILDRENS DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43205-2664
Mailing Address - Country:US
Mailing Address - Phone:614-722-4200
Mailing Address - Fax:614-722-4203
Practice Address - Street 1:700 CHILDRENS DR
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43205
Practice Address - Country:US
Practice Address - Phone:614-722-4200
Practice Address - Fax:614-722-4203
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2025-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH350951532080H0002X
OH35-095153208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080H0002XAllopathic & Osteopathic PhysiciansPediatricsHospice and Palliative Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHH185751OtherCGS - MEDICARE
OH3039161Medicaid