Basic Information
| Provider Information | |||||||||
| NPI: | 1285610774 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CAMPBELL | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | FREDERICK | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | CENTRACARE CLINIC RIVER CAMPUS | ||||||||
| Address2: | 1200 6TH AVENUE NORTH | ||||||||
| City: | ST CLOUD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563032735 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3206567024 | ||||||||
| FaxNumber: | 3206567026 | ||||||||
| Practice Location | |||||||||
| Address1: | 1200 6TH AVENUE NORTH | ||||||||
| Address2: | CENTRACARE CLINIC RIVER CAMPUS | ||||||||
| City: | ST CLOUD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563032735 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3206567024 | ||||||||
| FaxNumber: | 3206567026 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/16/2005 | ||||||||
| LastUpdateDate: | 11/17/2017 | ||||||||
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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 | 207V00000X | 25609 | MN | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 23232 | 01 | ARAZ | OTHER | 0641002 | 01 | PREFERRED ONE | OTHER | 0700012 | 01 | MEDICA PRIMARY | OTHER | 160001740 | 01 | METRAHEALTH MEDICARE | OTHER | 960980641002 | 01 | PEAK PROVIDER NUMBER | OTHER | D98325 | 01 | CHOICE PLUS | OTHER | 960980641002 | 01 | PREICH PROVIDER NUMBER | OTHER | 0707104 | 01 | MEDICA CHOICE | OTHER | 107165C280 | 01 | UCARE | OTHER | 32120700 | 01 | WISCONSIN MA | OTHER | HP13019 | 01 | EMHO | OTHER | 160046617 | 01 | RR MEDICARE | OTHER | 48B94CA | 01 | BCBS | OTHER | 532865900 | 01 | MN MEDICAL ASSISTANCE | OTHER | 532865900 | 05 | MN | MEDICAID | 0707103 | 01 | SELECT CARE | OTHER |