Healthcare Provider Details

I. General information

NPI: 1124750393
Provider Name (Legal Business Name): MARCELO ADAM CAMPA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2022
Last Update Date: 06/27/2022
Certification Date: 06/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

519 COURT ST
PORTSMOUTH OH
45662-3933
US

IV. Provider business mailing address

519 COURT ST
PORTSMOUTH OH
45662-3933
US

V. Phone/Fax

Practice location:
  • Phone: 740-876-4370
  • Fax:
Mailing address:
  • Phone: 740-876-4370
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberTP644148
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: