Basic Information
| Provider Information | |||||||||
| NPI: | 1235168691 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CAMPBELL | ||||||||
| FirstName: | BRADLEY | ||||||||
| MiddleName: | G | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 879 | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727020879 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4797137115 | ||||||||
| FaxNumber: | 4797137186 | ||||||||
| Practice Location | |||||||||
| Address1: | 3215 N NORTHHILLS BLVD | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727034007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4794631704 | ||||||||
| FaxNumber: | 4794635731 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 207R00000X | E-4824 | AR | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | BC0753257 | 01 | DEA | OTHER |