Provider Demographics
NPI:1003852039
Name:CAMPBELL, JOHNNY PHILLIPS (MD)
Entity Type:Individual
Prefix:
First Name:JOHNNY
Middle Name:PHILLIPS
Last Name:CAMPBELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2363
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46206-2363
Mailing Address - Country:US
Mailing Address - Phone:843-724-2154
Mailing Address - Fax:
Practice Address - Street 1:316 CALHOUN ST
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29401-1113
Practice Address - Country:US
Practice Address - Phone:843-724-2988
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2014-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC284432085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCQ01611Medicaid
SCP00396969OtherRR MEDICARE
SCQ01611Medicaid