Healthcare Provider Details

I. General information

NPI: 1821030859
Provider Name (Legal Business Name): MATTHEW CAMPBELL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2006
Last Update Date: 02/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 WESTERN AVE
MANITOWOC WI
54220-3712
US

IV. Provider business mailing address

PO BOX 2290
MANITOWOC WI
54221-2290
US

V. Phone/Fax

Practice location:
  • Phone: 920-320-3165
  • Fax:
Mailing address:
  • Phone: 920-320-2591
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number51519
License Number StateWI

VII. Legacy identifiers

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

# 1
Identifier1821030859
Identifier TypeOTHER
Identifier StateWI
Identifier IssuerBCBS
# 2
IdentifierP00688641
Identifier TypeOTHER
Identifier StateWI
Identifier IssuerRR MEDICARE
# 3
Identifier208600000X
Identifier TypeMEDICAID
Identifier StateWI
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: