Provider Demographics
NPI:1003000803
Name:CAMPBELL MEDICAL GROUP, MD, PSC
Entity Type:Organization
Organization Name:CAMPBELL MEDICAL GROUP, MD, PSC
Other - Org Name:CAMPBELL MEDICAL GROUP
Other - Org Type:Other Name
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:DALTON
Authorized Official - Last Name:GIBSON
Authorized Official - Suffix:
Authorized Official - Credentials:RHIT
Authorized Official - Phone:270-629-3772
Mailing Address - Street 1:303 PROFESSIONAL PARK DR
Mailing Address - Street 2:
Mailing Address - City:GLASGOW
Mailing Address - State:KY
Mailing Address - Zip Code:42141-3487
Mailing Address - Country:US
Mailing Address - Phone:270-629-3772
Mailing Address - Fax:270-629-3774
Practice Address - Street 1:303 PROFESSIONAL PARK DR
Practice Address - Street 2:
Practice Address - City:GLASGOW
Practice Address - State:KY
Practice Address - Zip Code:42141-3487
Practice Address - Country:US
Practice Address - Phone:270-629-3772
Practice Address - Fax:270-629-3774
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-05
Last Update Date:2007-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY33935207Q00000X
KY34221207RA0000X
KY4716P363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No207RA0000XAllopathic & Osteopathic PhysiciansInternal MedicineAdolescent MedicineGroup - Single Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64095326Medicaid
KY000000333249OtherBLUE CROSS BLUE SHIELD
KY000000360876OtherBLUE CROSS BLUE SHIELD
KY64019003Medicaid
KY0922102Medicare UPIN
KY64095326Medicaid
KY9221Medicare PIN