Provider Demographics
NPI:1972824720
Name:CAMPBELL, MATTHEW
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
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 1:1801 N WASHINGTON ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:TULLAHOMA
Mailing Address - State:TN
Mailing Address - Zip Code:37388-8245
Mailing Address - Country:US
Mailing Address - Phone:931-393-7060
Mailing Address - Fax:931-222-4303
Practice Address - Street 1:1801 N WASHINGTON ST
Practice Address - Street 2:SUITE 100
Practice Address - City:TULLAHOMA
Practice Address - State:TN
Practice Address - Zip Code:37388-8245
Practice Address - Country:US
Practice Address - Phone:931-393-7060
Practice Address - Fax:931-222-4303
Is Sole Proprietor?:No
Enumeration Date:2010-06-16
Last Update Date:2020-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA4148208000000X
TNMD49987208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics