1063413029 NPI number — SUSAN L CAMPBELL CNM

Table of content: SUSAN L CAMPBELL CNM (NPI 1063413029)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063413029 NPI number — SUSAN L CAMPBELL CNM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CAMPBELL
Provider First Name:
SUSAN
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CNM
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CAMPBELL
Provider Other First Name:
SUE
Provider Other Middle Name:
L
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
CNM
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1063413029
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/09/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
90 JACKSON PIKE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GALLIPOLIS
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45631-1560
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
740-589-3100
Provider Business Mailing Address Fax Number:
740-589-3123

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2131 EAST STATE ST.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ATHENS
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45701
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
740-589-3100
Provider Business Practice Location Address Fax Number:
740-589-3123
Provider Enumeration Date:
08/02/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 367A00000X , with the licence number:  APRN.CNM.10196 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 000000259823 . This is a "OH MEDICAID UNISON" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 2882288 . This is a "OH MEDICAID MOLINA" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 2882288 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00665594 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 310917085201 . This is a "OH MEDICAID CARESOURCE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 3810013422 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".




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