Individual
JON O HUMPHREY
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
305 W JACKSON ST, SUITE 200, CARBONDALE, IL 62901-1474
(618) 453-3777
(618) 453-1102
Mailing address
701 N 1ST ST, PO BOX 19639, SPRINGFIELD, IL 62794-9639
(217) 545-7578
(217) 545-1884
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
67471
TN
207QS0010X
Sports Medicine (Family Medicine) Physician
036-116062
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
036116062
—
IL
Enumeration date
06/29/2007
Last updated
06/10/2024
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