Healthcare Provider Details

I. General information

NPI: 1003000803
Provider Name (Legal Business Name): CAMPBELL MEDICAL GROUP, MD, PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/05/2007
Last Update Date: 12/05/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

303 PROFESSIONAL PARK DR
GLASGOW KY
42141-3487
US

IV. Provider business mailing address

303 PROFESSIONAL PARK DR
GLASGOW KY
42141-3487
US

V. Phone/Fax

Practice location:
  • Phone: 270-629-3772
  • Fax: 270-629-3774
Mailing address:
  • Phone: 270-629-3772
  • Fax: 270-629-3774

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RA0000X
TaxonomyAdolescent Medicine (Internal Medicine) Physician
License Number34221
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number4716P
License Number StateKY
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number33935
License Number StateKY

VIII. Authorized Official

Name: MS. JENNIFER DALTON GIBSON
Title or Position: OFFICE MANAGER
Credential: RHIT
Phone: 270-629-3772