MEDICARE: DR. CHARLES D CAMPBELL M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208G00000X	Thoracic Surgery (Cardiothoracic Vascular Surgery) Physician	036-054924	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1518969245
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CHARLES D CAMPBELL M.D.

Provider Business Mailing Address
First Line	:	357 N CANAL ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60606-1207
Country	:	US
Telephone Number	:	312-961-9632
Fax Number	:	312-831-1250

Provider Business Practice Location Address
First Line	:	2525 S MICHIGAN AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60616-2333
Country	:	US
Telephone Number	:	312-961-9632
Fax Number	:	312-831-1250

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/12/2005
Last Update Date	:	08/17/2010

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