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General NPI Number Information
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NPI Number | 1629258132
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Entity Type | Individual
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Provider Name | MARY L. CAMPAGNA-GIBSON M.D.
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Gender | Female
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Dates
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Enumeration Date | 11/13/2007
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Last Update Date | 02/18/2014
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Provider Practice Location Address
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Address Line | 6308 8TH AVE SUITE 2000
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City | KENOSHA
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State | WI
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Zip | 53143-5031
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Country | US
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Telephone | 262-653-5300
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Fax | 262-653-5412
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Provider Business Mailing Address
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Address Line | 6308 8TH AVE SUITE 2000
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City | KENOSHA
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State | WI
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Zip | 53143-5031
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Country | US
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Telephone | 262-653-5300
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Fax | 262-653-5412
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084N0400X
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Taxonomy Name | Neurology Physician
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License Number | 2008-01613
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License Number State | NC
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