Healthcare Provider Details

I. General information

NPI: 1023263589
Provider Name (Legal Business Name): CAMPBELL MEDICAL SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/25/2008
Last Update Date: 11/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

755 CAMPBELL AVE SUITE 3
WEST HAVEN CT
06516-3715
US

IV. Provider business mailing address

755 CAMPBELL AVE SUITE 3
WEST HAVEN CT
06516-3715
US

V. Phone/Fax

Practice location:
  • Phone: 203-937-1100
  • Fax: 203-937-1102
Mailing address:
  • Phone: 203-937-1100
  • Fax: 203-937-1102

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036182
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number005583
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number002961
License Number StateCT

VIII. Authorized Official

Name: CHANNA D. PERERA
Title or Position: OWNER
Credential: M.D.
Phone: 203-937-1100