Provider Demographics
NPI:1629258132
Name:CAMPAGNA-GIBSON, MARY L (MD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:L
Last Name:CAMPAGNA-GIBSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6308 8TH AVE
Mailing Address - Street 2:SUITE 2000
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53143-5031
Mailing Address - Country:US
Mailing Address - Phone:262-653-5300
Mailing Address - Fax:262-653-5412
Practice Address - Street 1:6308 8TH AVE
Practice Address - Street 2:SUITE 2000
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53143-5031
Practice Address - Country:US
Practice Address - Phone:262-653-5300
Practice Address - Fax:262-653-5412
Is Sole Proprietor?:No
Enumeration Date:2007-11-13
Last Update Date:2014-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2008-016132084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCN0161GMedicaid
WI1629258132Medicaid
NC5911767Medicaid
NC5911767Medicaid
NC41099BMedicare UPIN
WIK400097204Medicare PIN