Provider Demographics
NPI: | 1780816447 |
---|---|
Name: | CAMPBELL, AUDREY L (DO) |
Entity Type: | Individual |
Prefix: | DR |
First Name: | AUDREY |
Middle Name: | L |
Last Name: | CAMPBELL |
Suffix: | |
Gender: | F |
Credentials: | DO |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 215 E SPRINGBROOK DR |
Mailing Address - Street 2: | |
Mailing Address - City: | JOHNSON CITY |
Mailing Address - State: | TN |
Mailing Address - Zip Code: | 37601-1761 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 423-794-5520 |
Mailing Address - Fax: | 423-282-6940 |
Practice Address - Street 1: | 301 MED TECH PKWY STE 240 |
Practice Address - Street 2: | |
Practice Address - City: | JOHNSON CITY |
Practice Address - State: | TN |
Practice Address - Zip Code: | 37604-2641 |
Practice Address - Country: | US |
Practice Address - Phone: | 423-794-5520 |
Practice Address - Fax: | 423-282-6940 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2009-08-13 |
Last Update Date: | 2020-04-27 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
VA | 0116021790 | 207R00000X |
TN | 2439 | 207R00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
NC | 1780816447 | Medicaid | |
VA | 1780816447 | Medicaid | |
TN | Q000732 | Medicaid | |
KY | 7100238500 | Medicaid | |
TN | P01302087 | Other | RR MEDICARE |
TN | 103I116063 | Medicare PIN |