Basic Information
| Provider Information | |||||||||
| NPI: | 1215953310 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CAMPBELL | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 720 S COLORADO BLVD | ||||||||
| Address2: | SUITE 220A | ||||||||
| City: | GLENDALE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802461912 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3035848231 | ||||||||
| FaxNumber: | 8662100907 | ||||||||
| Practice Location | |||||||||
| Address1: | 12207 PECOS ST | ||||||||
| Address2: | #300 | ||||||||
| City: | WESTMINSTER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800313400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3036500445 | ||||||||
| FaxNumber: | 3034295088 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2006 | ||||||||
| LastUpdateDate: | 02/24/2010 | ||||||||
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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 | 363AM0700X | 46 | CO | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | C811604 | 01 | CO | MEDICARE GROUP NUMBER | OTHER | 011500 | 01 | CO | KAISER COMMERCIAL NUMBER | OTHER | 348308 | 01 | CO | MEDICARE GROUP PTAN | OTHER | 98579274 | 05 | CO | MEDICAID |