Provider Demographics
NPI:1851392948
Name:CAMPBELL, MARK G (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:G
Last Name:CAMPBELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:5800 FOREMOST DR SE STE 300
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-7062
Mailing Address - Country:US
Mailing Address - Phone:616-954-9800
Mailing Address - Fax:
Practice Address - Street 1:145 MICHIGAN ST NE STE 3100
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-2563
Practice Address - Country:US
Practice Address - Phone:616-954-9800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2020-03-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301036444207RX0202X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI900000362OtherRR MEDICARE
MI900000362OtherRR MEDICARE
MIM08620002Medicare PIN