Provider Demographics
NPI:1205991619
Name:CAMPBELL, JOHN (PT)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:CAMPBELL
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 ENTERPRISE DR.
Mailing Address - Street 2:
Mailing Address - City:OAK BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60523
Mailing Address - Country:US
Mailing Address - Phone:630-575-6250
Mailing Address - Fax:630-575-7450
Practice Address - Street 1:530 W NORTH ST
Practice Address - Street 2:SUITE 101
Practice Address - City:MANHATTAN
Practice Address - State:IL
Practice Address - Zip Code:60442-8176
Practice Address - Country:US
Practice Address - Phone:815-478-7444
Practice Address - Fax:815-478-7447
Is Sole Proprietor?:No
Enumeration Date:2006-12-26
Last Update Date:2017-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X
IL070003674225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL070-003674OtherPT STATE LICENSE #