=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669502670
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WADSWORTH FOOT & ANKLE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/07/2007
-----------------------------------------------------
Last Update Date | 05/08/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 229 LEATHERMAN RD
-----------------------------------------------------
City | WADSWORTH
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44281-9236
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-336-7075
-----------------------------------------------------
Fax | 330-336-4211
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 229 LEATHERMAN RD
-----------------------------------------------------
City | WADSWORTH
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44281-9236
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-336-7075
-----------------------------------------------------
Fax | 330-336-4211
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. PATRICK ANTHONY CAMPBELL
-----------------------------------------------------
Credential | D.P.M.
-----------------------------------------------------
Telephone | 330-336-7075
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213ES0103X
-----------------------------------------------------
Taxonomy Name | Foot & Ankle Surgery Podiatrist
-----------------------------------------------------
License Number | 36003282
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------