Healthcare Provider Details

I. General information

NPI: 1780790147
Provider Name (Legal Business Name): LANNY F CAMPBELL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2006
Last Update Date: 08/25/2023
Certification Date: 08/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1308 8TH ST STE 1
RUPERT ID
83350-1535
US

IV. Provider business mailing address

1224 8TH STREET
RUPERT ID
83350-1527
US

V. Phone/Fax

Practice location:
  • Phone: 208-436-4322
  • Fax: 208-436-1312
Mailing address:
  • Phone: 208-434-8236
  • Fax: 208-436-6038

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberM-8031
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberM-8031
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: