Provider Demographics
NPI:1295813475
Name:CLAY I. CAMPBELL M.D.,P.C.
Entity Type:Organization
Organization Name:CLAY I. CAMPBELL M.D.,P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CLAY
Authorized Official - Middle Name:I
Authorized Official - Last Name:CAMPBELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-847-3847
Mailing Address - Street 1:166 S 5TH ST
Mailing Address - Street 2:
Mailing Address - City:MONTPELIER
Mailing Address - State:ID
Mailing Address - Zip Code:83254-1557
Mailing Address - Country:US
Mailing Address - Phone:208-847-3847
Mailing Address - Fax:208-847-1620
Practice Address - Street 1:166 S 5TH ST
Practice Address - Street 2:
Practice Address - City:MONTPELIER
Practice Address - State:ID
Practice Address - Zip Code:83254-1557
Practice Address - Country:US
Practice Address - Phone:208-847-3847
Practice Address - Fax:208-847-1620
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-02
Last Update Date:2010-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-6056207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806820000Medicaid
ID1377008Medicare Oscar/Certification
ID133851Medicare Oscar/Certification
IDF72791Medicare UPIN
IDQ25275Medicare UPIN