Provider Demographics
NPI:1467438770
Name:CAMPBELL, BRUCE EDGAR
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:EDGAR
Last Name:CAMPBELL
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:BRUCE
Other - Middle Name:
Other - Last Name:CAMPBELL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:5724 WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37921-2224
Mailing Address - Country:US
Mailing Address - Phone:719-640-7595
Mailing Address - Fax:
Practice Address - Street 1:5724 WESTERN AVE
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37921-2224
Practice Address - Country:US
Practice Address - Phone:719-640-7595
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-19
Last Update Date:2025-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN47531207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO44382871Medicaid
COH88574Medicare UPIN
COCO300699Medicare PIN
CO44382871Medicaid