Healthcare Provider Details

I. General information

NPI: 1861676173
Provider Name (Legal Business Name): MARY BETH CAMPBELL NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/21/2007
Last Update Date: 09/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2800 MAIN ST HOSPITALIST DEPT
BRIDGEPORT CT
06606-4201
US

IV. Provider business mailing address

2800 MAIN ST ST. VINCENT MULTISPECIALTY GROUP
BRIDGEPORT CT
06606-4201
US

V. Phone/Fax

Practice location:
  • Phone: 203-576-6000
  • Fax:
Mailing address:
  • Phone: 203-576-6000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number004930
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number235123
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: