Healthcare Provider Details

I. General information

NPI: 1740293976
Provider Name (Legal Business Name): ORVILLE LEE CAMPBELL PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2006
Last Update Date: 09/17/2026
Certification Date: 09/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1040 EDGEWATER CORPORATE PKWY STE 106
INDIAN LAND SC
29707-4526
US

IV. Provider business mailing address

1040 EDGEWATER CORPORATE PKWY STE 106
INDIAN LAND SC
29707-4526
US

V. Phone/Fax

Practice location:
  • Phone: 803-913-4500
  • Fax: 855-576-4972
Mailing address:
  • Phone: 803-913-4500
  • Fax: 855-576-4972

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number103762
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number103762
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: