=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922187285
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MR. WALTER PHILIP CAMPBELL
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/06/2006
-----------------------------------------------------
Last Update Date | 11/02/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2692 N UNIVERSITY DR SUITE 10
-----------------------------------------------------
City | SUNRISE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33322-2496
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-749-4420
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4631 NW 93RD AVE
-----------------------------------------------------
City | SUNRISE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33351-5239
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-242-0465
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number | 1360
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------