Provider Demographics
NPI:1114194586
Name:RALPH P CAMPANALE MD PC
Entity Type:Organization
Organization Name:RALPH P CAMPANALE MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RALPH
Authorized Official - Middle Name:P
Authorized Official - Last Name:CAMPANALE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-726-3707
Mailing Address - Street 1:PO BOX 3778
Mailing Address - Street 2:
Mailing Address - City:KETCHUM
Mailing Address - State:ID
Mailing Address - Zip Code:83340-3778
Mailing Address - Country:US
Mailing Address - Phone:208-726-3707
Mailing Address - Fax:208-726-4817
Practice Address - Street 1:180 WEST 1ST ST
Practice Address - Street 2:SUITE 301
Practice Address - City:KETCHUM
Practice Address - State:ID
Practice Address - Zip Code:83340
Practice Address - Country:US
Practice Address - Phone:208-726-3707
Practice Address - Fax:208-726-4817
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-14
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM4961174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002699100Medicaid
IDC47891Medicare UPIN