1477597912 NPI number — TOM G CAMPBELL MD

Table of content: TOM G CAMPBELL MD (NPI 1477597912)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477597912 NPI number — TOM G CAMPBELL MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CAMPBELL
Provider First Name:
TOM
Provider Middle Name:
G
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1477597912
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/28/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1208
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MONTROSE
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
81402-1208
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
970-252-3200
Provider Business Mailing Address Fax Number:
970-252-3208

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2130 E MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MONTROSE
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
81401-3834
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
970-252-3200
Provider Business Practice Location Address Fax Number:
970-252-3208
Provider Enumeration Date:
06/15/2006

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: 2084P0800X , with the licence number:  30613 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 84-0561224 . This is a "TAX ID" identifier , issued by the state of ( CO ) . This identifiers is of the category "OTHER".




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