Basic Information
| Provider Information | |||||||||
| NPI: | 1023287745 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CAMPBELL | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | CLEVELAND | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1040 SIERRA DR | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | GREENWOOD | ||||||||
| State: | IN | ||||||||
| PostalCode: | 461437240 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3175284800 | ||||||||
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| Practice Location | |||||||||
| Address1: | 18636 DIXIE HWY | ||||||||
| Address2: | |||||||||
| City: | HOMEWOOD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604303741 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7086470571 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/27/2008 | ||||||||
| LastUpdateDate: | 05/11/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 036119743 | IL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1619280203 | 01 | IL | GROUP NPI # | OTHER | IL5686006 | 01 | IL | MEDICARE PTAN | OTHER | 36-2167869 | 01 | IL | GROUP TAX ID | OTHER |