Healthcare Provider Details

I. General information

NPI: 1740513431
Provider Name (Legal Business Name): MR. CHARLES DOUGLAS CAMPBELL JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/11/2009
Last Update Date: 09/11/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2018 217TH ST
SAUK VILLAGE IL
60411-4521
US

IV. Provider business mailing address

4743 N KILBOURN AVE
CHICAGO IL
60630-4006
US

V. Phone/Fax

Practice location:
  • Phone: 773-283-1742
  • Fax: 773-283-1742
Mailing address:
  • Phone: 773-283-1742
  • Fax: 773-283-1742

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: