Provider Demographics
NPI:1700808979
Name:CAMPBELL, BERRY ALLEN (MD)
Entity Type:Individual
Prefix:
First Name:BERRY
Middle Name:ALLEN
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:PO BOX 743904
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-3904
Mailing Address - Country:US
Mailing Address - Phone:803-293-7320
Mailing Address - Fax:803-296-7330
Practice Address - Street 1:2 MEDICAL PARK RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-6808
Practice Address - Country:US
Practice Address - Phone:803-545-5700
Practice Address - Fax:803-434-6642
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2020-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY28208207VM0101X
SC13001207VM0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000219605OtherANTHEM BCBS
SC13001OtherMEDICAL LICENSE
SC130012Medicaid
KY64282080Medicaid
SC130012Medicaid
KY64282080Medicaid
KY0732401Medicare PIN
SC13001OtherMEDICAL LICENSE