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NPI Code Detail

MEDICARE: MARK CAMPBELL CRNA

MEDICARE: MARK CAMPBELL CRNA
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
1367500000XCertified Registered Nurse Anesthetist4704194477MI

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MC194477OTHERMIBLUE CROSS

General Provider Information

NPI Number : 1538151238
Entity Type Code : Individual
Provider Name (Legal Business Name) : MARK CAMPBELL CRNA
Provider Business Mailing Address
First Line : PO BOX 67000
Second Line : DEPT 203401
City : DETROIT
State : MI
Zip : 48267-0002
Country : US
Telephone Number : 952-442-9770
Fax Number :
Provider Business Practice Location Address
First Line : 3901 BEAUBIEN ST
Second Line :
City : DETROIT
State : MI
Zip : 48201-2119
Country : US
Telephone Number : 952-442-9770
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 08/18/2005
Last Update Date : 07/08/2007

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