Provider Demographics
NPI:1740991967
Name:CAMPBELL, MICHAEL SCOTT
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:SCOTT
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 1:707 S BOWER ST
Mailing Address - Street 2:
Mailing Address - City:KNOX
Mailing Address - State:IN
Mailing Address - Zip Code:46534-1906
Mailing Address - Country:US
Mailing Address - Phone:574-540-3655
Mailing Address - Fax:
Practice Address - Street 1:916 RAVINE DR
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:IN
Practice Address - Zip Code:46131-3609
Practice Address - Country:US
Practice Address - Phone:574-540-3655
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-08
Last Update Date:2022-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN0750-08-0724172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver