1821065509 NPI number — MR. JONATHAN CROSS CAMPBELL III MD

Table of content: MR. JONATHAN CROSS CAMPBELL III MD (NPI 1821065509)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821065509 NPI number — MR. JONATHAN CROSS CAMPBELL III MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CAMPBELL
Provider First Name:
JONATHAN
Provider Middle Name:
CROSS
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
III
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:
CAMPBELL
Provider Other First Name:
JONATHAN
Provider Other Middle Name:
C
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
III
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1821065509
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/11/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7505 MOFFETT RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MOBILE
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
36618-4193
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
251-649-6112
Provider Business Mailing Address Fax Number:
251-649-6115

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5320 HIGHWAY 90 W
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOBILE
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36619-4202
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
251-666-8232
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/02/2006

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: 207Q00000X , with the licence number:  15993 , 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)

  • Identifier: P00111807 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 051519758 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".




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