Healthcare Provider Details

I. General information

NPI: 1710294756
Provider Name (Legal Business Name): TRACY CAMPBELL MD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/13/2010
Last Update Date: 03/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

675 W NORTH AVE STE 506
MELROSE PARK IL
60160-1626
US

IV. Provider business mailing address

675 W NORTH AVE STE 506
MELROSE PARK IL
60160-1626
US

V. Phone/Fax

Practice location:
  • Phone: 708-450-5086
  • Fax: 708-345-4075
Mailing address:
  • Phone: 708-450-5086
  • Fax: 708-345-4075

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number036120737
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number036120737
License Number StateIL

VIII. Authorized Official

Name: TRACY CAMPBELL
Title or Position: SOLE PROPRIETOR
Credential: M.D.
Phone: 708-450-5086