Healthcare Provider Details

I. General information

NPI: 1518969245
Provider Name (Legal Business Name): CHARLES D CAMPBELL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2005
Last Update Date: 08/17/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2525 S MICHIGAN AVE
CHICAGO IL
60616-2333
US

IV. Provider business mailing address

357 N CANAL ST
CHICAGO IL
60606-1207
US

V. Phone/Fax

Practice location:
  • Phone: 312-961-9632
  • Fax: 312-831-1250
Mailing address:
  • Phone: 312-961-9632
  • Fax: 312-831-1250

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number036-054924
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: