Healthcare Provider Details

I. General information

NPI: 1205921574
Provider Name (Legal Business Name): CHARLES LARRY CAMPBELL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 10/18/2024
Certification Date: 10/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19 DOCTORS WAY STE C
BLAIRSVILLE GA
30512-1118
US

IV. Provider business mailing address

19 DOCTORS WAY STE C
BLAIRSVILLE GA
30512-1118
US

V. Phone/Fax

Practice location:
  • Phone: 706-439-6380
  • Fax:
Mailing address:
  • Phone: 706-439-6380
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number52031
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number52031
License Number StateTN
# 3
Primary TaxonomyN
Taxonomy Code207RA0001X
TaxonomyAdvanced Heart Failure and Transplant Cardiology Physician
License Number52031
License Number StateTN
# 4
Primary TaxonomyY
Taxonomy Code207RA0001X
TaxonomyAdvanced Heart Failure and Transplant Cardiology Physician
License Number82064
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: