Provider Demographics
NPI:1972581718
Name:CAMPBELL, PAUL E
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:E
Last Name:CAMPBELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:46675 HOUGHTON DR
Mailing Address - Street 2:
Mailing Address - City:SHELBY TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48315-5261
Mailing Address - Country:US
Mailing Address - Phone:586-731-2954
Mailing Address - Fax:
Practice Address - Street 1:18303 E 10 MILE RD
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:MI
Practice Address - Zip Code:48066-4988
Practice Address - Country:US
Practice Address - Phone:586-498-5160
Practice Address - Fax:586-498-5199
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-03
Last Update Date:2008-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101006340207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI08-5503076-4OtherBCBSM PIN #
MI4300056OtherAETNA
MIM007586OtherTRICARE PROVIDER ID
MI4300056OtherAETNA
MI5503076Medicare ID - Type UnspecifiedMEDICARE PROVIDER ID
MIM007586OtherTRICARE PROVIDER ID