Healthcare Provider Details

I. General information

NPI: 1205285517
Provider Name (Legal Business Name): SCOTT CAMPBELL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/07/2016
Last Update Date: 06/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

147 BURROWES ROAD 147 RECREATION HALL
UNIVERSITY PARK PA
16802-0147
US

IV. Provider business mailing address

147 RECREATION HALL
UNIVERSITY PARK PA
16802
US

V. Phone/Fax

Practice location:
  • Phone: 814-867-0476
  • Fax:
Mailing address:
  • Phone: 814-867-0476
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberRT005216
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: