Provider Demographics
NPI:1184680662
Name:CAMPBELL, TODD GARRISON (MD)
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:GARRISON
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 1:18325 E 10 MILE RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:ROSEVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48066-4990
Mailing Address - Country:US
Mailing Address - Phone:586-773-6300
Mailing Address - Fax:586-773-6266
Practice Address - Street 1:18325 E 10 MILE RD
Practice Address - Street 2:SUITE 200
Practice Address - City:ROSEVILLE
Practice Address - State:MI
Practice Address - Zip Code:48066-4990
Practice Address - Country:US
Practice Address - Phone:586-773-6300
Practice Address - Fax:586-773-6266
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2008-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MITC075516208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI340018342OtherRAILROAD MEDICARE PIN
MI4175785Medicaid
MI3405009731OtherBCBSM
MITC075516OtherLICENSE
MITC075516OtherLICENSE
MI1005840001Medicare NSC
MI4175785Medicaid