Provider Demographics
NPI:1972506665
Name:CAMPBELL, THOMAS J (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:J
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 1:800 AUSTIN ST
Mailing Address - Street 2:STE 451E
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60202-3455
Mailing Address - Country:US
Mailing Address - Phone:847-316-6611
Mailing Address - Fax:
Practice Address - Street 1:800 AUSTIN ST
Practice Address - Street 2:STE 451E
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60202-3455
Practice Address - Country:US
Practice Address - Phone:847-316-6611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-05-27
Last Update Date:2021-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036042217207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036042217Medicaid
ILC44490Medicare UPIN
IL391910Medicare ID - Type Unspecified