Provider Demographics
NPI:1518969245
Name:CAMPBELL, CHARLES D (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:D
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 1:357 N CANAL ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60606-1207
Mailing Address - Country:US
Mailing Address - Phone:312-961-9632
Mailing Address - Fax:312-831-1250
Practice Address - Street 1:2525 S MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60616-2333
Practice Address - Country:US
Practice Address - Phone:312-961-9632
Practice Address - Fax:312-831-1250
Is Sole Proprietor?:No
Enumeration Date:2005-08-12
Last Update Date:2010-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-054924208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036054924Medicaid
ILL99379Medicare PIN
ILIL3488Medicare PIN
ILD89295Medicare UPIN
IL036054924Medicaid