MEDICARE: DR. PENELOPE ANNE CAMPBELL MD

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	2080A0000X	Pediatric Adolescent Medicine Physician	27349	SC
2	208000000X	Pediatrics Physician	27349	SC

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	7844	OTHER	SC	MEDICARE PTAN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	570783896	OTHER	SC	FED TAX ID
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1124084876
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. PENELOPE ANNE CAMPBELL MD

Provider Business Mailing Address
First Line	:	PO BOX 50760
Second Line	:
City	:	MYRTLE BEACH
State	:	SC
Zip	:	29579-0013
Country	:	US
Telephone Number	:	843-903-4111
Fax Number	:	843-903-4242

Provider Business Practice Location Address
First Line	:	4022 POSTAL WAY STE C
Second Line	:
City	:	MYRTLE BEACH
State	:	SC
Zip	:	29579-3537
Country	:	US
Telephone Number	:	843-903-4111
Fax Number	:	843-903-4242

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

Provider Enumeration Date	:	04/21/2006
Last Update Date	:	02/02/2012

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