Provider Demographics
NPI:1073583621
Name:CAMPBELL, THERESA M (MD)
Entity Type:Individual
Prefix:MRS
First Name:THERESA
Middle Name:M
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2200 N KIMBALL ST
Mailing Address - Street 2:STE 400
Mailing Address - City:MITCHELL
Mailing Address - State:SD
Mailing Address - Zip Code:57301-1199
Mailing Address - Country:US
Mailing Address - Phone:605-996-7900
Mailing Address - Fax:605-996-7908
Practice Address - Street 1:2200 N KIMBALL ST
Practice Address - Street 2:STE 400
Practice Address - City:MITCHELL
Practice Address - State:SD
Practice Address - Zip Code:57301-1199
Practice Address - Country:US
Practice Address - Phone:605-996-7900
Practice Address - Fax:605-996-7908
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-25
Last Update Date:2008-09-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
SD3969207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD5602053Medicaid
P00044414Medicare PIN
SD5602053Medicaid