1659409365 NPI number — MR. KENNETH WAYNE CAMPBELL CRNA

Table of content: MR. KENNETH WAYNE CAMPBELL CRNA (NPI 1659409365)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659409365 NPI number — MR. KENNETH WAYNE CAMPBELL CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CAMPBELL
Provider First Name:
KENNETH
Provider Middle Name:
WAYNE
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
CRNA
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CAMPBELL
Provider Other First Name:
KENNETH
Provider Other Middle Name:
WAYNE
Provider Other Name Prefix Text:
PROF.
Provider Other Name Suffix Text:
Provider Other Credential Text:
CRNA
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1659409365
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
727 COUNTY ROAD 8
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HEFLIN
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
36264-3651
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
256-253-2885
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1701 PELHAM ROAD
Provider Second Line Business Practice Location Address:
JACKSONVILLE MEDICAL CENTER
Provider Business Practice Location Address City Name:
JACKSONVILLE
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36265
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
256-435-4970
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/02/2007

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: 367500000X , with the licence number:  26081 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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