Provider Demographics
NPI:1598853608
Name:JOHN N CAMPBELL MD PC
Entity Type:Organization
Organization Name:JOHN N CAMPBELL MD PC
Other - Org Name:GRAND MEDICAL ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:NELSON
Authorized Official - Last Name:CAMPBELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:616-455-9450
Mailing Address - Street 1:1676 VIEWPOND DRIVE SE
Mailing Address - Street 2:SUITE 100A
Mailing Address - City:KENTWOOD
Mailing Address - State:MI
Mailing Address - Zip Code:49508
Mailing Address - Country:US
Mailing Address - Phone:616-455-9450
Mailing Address - Fax:616-455-5221
Practice Address - Street 1:1676 VIEWPOND DRIVE SE
Practice Address - Street 2:SUITE 100A
Practice Address - City:KENTWOOD
Practice Address - State:MI
Practice Address - Zip Code:49508
Practice Address - Country:US
Practice Address - Phone:616-455-9450
Practice Address - Fax:616-455-5221
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JOHN N CAMPBELL MD PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-11
Last Update Date:2022-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI034105207R00000X
291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No291U00000XLaboratoriesClinical Medical LaboratoryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1076881Medicaid
0P28470Medicare PIN
MIB45563Medicare UPIN
MI1076881Medicaid
B45563Medicare PIN