Healthcare Provider Details

I. General information

NPI: 1215935838
Provider Name (Legal Business Name): DIANE L CAMPBELL MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2005
Last Update Date: 07/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 GAY ST
ERWIN TN
37650-1228
US

IV. Provider business mailing address

PO BOX 759
ERWIN TN
37650-0759
US

V. Phone/Fax

Practice location:
  • Phone: 423-743-8400
  • Fax: 423-743-6888
Mailing address:
  • Phone: 423-743-8400
  • Fax: 423-743-6888

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberMD25069
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: