=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639540081
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SETH CAMPBELL
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/12/2015
-----------------------------------------------------
Last Update Date | 10/12/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 76 LOU GROZA BLVD
-----------------------------------------------------
City | BEREA
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44017-1238
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 440-824-3434
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 146 KEEFER RD
-----------------------------------------------------
City | CONNELLSVILLE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15425-6052
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 724-317-4179
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number | 004865
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------