Provider Demographics
NPI:1104017227
Name:C. E. CAMPBELL, JR MD PA
Entity Type:Organization
Organization Name:C. E. CAMPBELL, JR MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:LYNDA
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-763-0855
Mailing Address - Street 1:609 FULTON ST
Mailing Address - Street 2:
Mailing Address - City:BLYTHEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72315-1922
Mailing Address - Country:US
Mailing Address - Phone:870-763-0855
Mailing Address - Fax:870-763-0858
Practice Address - Street 1:609 FULTON ST
Practice Address - Street 2:
Practice Address - City:BLYTHEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72315-1922
Practice Address - Country:US
Practice Address - Phone:870-763-0855
Practice Address - Fax:870-763-0858
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-05
Last Update Date:2011-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARR1755174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR103491002Medicaid
MO501821003Medicaid
AR103491002OtherMEDICAID (GROUP)
AR1114934353OtherINDIVIDUAL NPI
AR1104017227OtherGROUP NPI
AR57299Medicare PIN
AR1104017227OtherGROUP NPI