Basic Information
Provider Information | |||||||||
NPI: | 1639135775 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CAMPBELL | ||||||||
FirstName: | MICHAEL | ||||||||
MiddleName: | G | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | CAMPBELL | ||||||||
OtherFirstName: | MICHAEL | ||||||||
OtherMiddleName: | GREGG | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MD | ||||||||
OtherLastNameType: | 2 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 9178 | ||||||||
Address2: |   | ||||||||
City: | RUSSELLVILLE | ||||||||
State: | AR | ||||||||
PostalCode: | 728119178 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8554986765 | ||||||||
FaxNumber: | 4799681673 | ||||||||
Practice Location | |||||||||
Address1: | 476 HOSPITAL DR | ||||||||
Address2: |   | ||||||||
City: | CAMDEN | ||||||||
State: | AR | ||||||||
PostalCode: | 717014616 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8708365738 | ||||||||
FaxNumber: | 8708365978 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/26/2006 | ||||||||
LastUpdateDate: | 08/08/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/08/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | L0767 | TX | N |   | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |   | 207V00000X | E15721 | AR | Y |   | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |   |
ID Information
ID | Type | State | Issuer | Description | 0026EY | 01 |   | BCBS | OTHER | 29665901 | 05 | TX |   | MEDICAID |