MEDICARE: TIMOTHY JAMES 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
1	367500000X	Certified Registered Nurse Anesthetist	28132356A	IN

General Provider Information

NPI Number	:	1578651741
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TIMOTHY JAMES CAMPBELL CRNA

Provider Business Mailing Address
First Line	:	202 S MEADOWHILL LN
Second Line	:
City	:	MAHOMET
State	:	IL
Zip	:	61853-8521
Country	:	US
Telephone Number	:	217-586-2564
Fax Number	:

Provider Business Practice Location Address
First Line	:	7988 W COUNTY ROAD 350 N
Second Line	:
City	:	SAINT PAUL
State	:	IN
Zip	:	47272-9783
Country	:	US
Telephone Number	:	217-841-4500
Fax Number	:

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

Provider Enumeration Date	:	10/11/2006
Last Update Date	:	07/08/2007

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