MEDICARE: DR. BRIAN MATTHEW CAMPBELL PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	PY0004142	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0005337111	OTHER	FL	AETNA PIN BRIAN CAMPBELL
2	1467491829	OTHER	FL	NPI NEW LIFE CHRISTIAN C
3	73535	OTHER	FL	BLUE CROSS BLUE SHIELD
4	053111	OTHER	FL	VALUE OPTIONS

General Provider Information

NPI Number	:	1093863466
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BRIAN MATTHEW CAMPBELL PH.D.

Provider Business Mailing Address
First Line	:	405 WAYMONT CT
Second Line	:	SUITE 111
City	:	LAKE MARY
State	:	FL
Zip	:	32746-3586
Country	:	US
Telephone Number	:	407-322-6868
Fax Number	:

Provider Business Practice Location Address
First Line	:	405 WAYMONT CT
Second Line	:	SUITE 111
City	:	LAKE MARY
State	:	FL
Zip	:	32746-3586
Country	:	US
Telephone Number	:	407-322-6868
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/08/2007
Last Update Date	:	07/08/2007

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