Provider Demographics
NPI:1972642916
Name:HUMPHREY, PETER EDWARD JR (MD)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:EDWARD
Last Name:HUMPHREY
Suffix:JR
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 1:1000 N OAK AVE
Mailing Address - Street 2:
Mailing Address - City:MARSHFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:54449-5703
Mailing Address - Country:US
Mailing Address - Phone:715-387-5511
Mailing Address - Fax:
Practice Address - Street 1:2116 CRAIG RD
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54701
Practice Address - Country:US
Practice Address - Phone:715-858-4500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI692922085R0202X
NM2004-02572085R0202X
NMMD2008-03582085R0202X
MA2431302085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110086115AMedicaid
MA001596901Medicare PIN