Provider Demographics
NPI:1548372873
Name:RANDALL HUMPHREYS P A
Entity type:Organization
Organization Name:RANDALL HUMPHREYS P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:F
Authorized Official - Last Name:HUMPHREYS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:850-785-2717
Mailing Address - Street 1:2401 SAINT ANDREWS BLVD
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32405-2170
Mailing Address - Country:US
Mailing Address - Phone:850-785-2717
Mailing Address - Fax:850-785-2301
Practice Address - Street 1:2401 SAINT ANDREWS BLVD
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405-2170
Practice Address - Country:US
Practice Address - Phone:850-785-2717
Practice Address - Fax:850-785-2301
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2010-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME59222207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL052572300Medicaid
FL12097OtherBCBS OF FLORIDA
FL052572300Medicaid