MEDICARE: LACHELLE CAMPBELL M.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	207Q00000X	Family Medicine Physician	D86104	MD
2	207Q00000X	Family Medicine Physician	2011-01176	NC
3	390200000X	Student in an Organized Health Care Education/Training Program	BP10030920	TX
4	207Q00000X	Family Medicine Physician	0101252713	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	C09633	OTHER	VA	GROUP PTAN

General Provider Information

NPI Number	:	1184870271
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LACHELLE CAMPBELL M.D.

Provider Business Mailing Address
First Line	:	13540 HULL STREET RD
Second Line	:
City	:	MIDLOTHIAN
State	:	VA
Zip	:	23112-2107
Country	:	US
Telephone Number	:	804-739-6142
Fax Number	:	804-739-8923

Provider Business Practice Location Address
First Line	:	504 E RIDGEVILLE BLVD STE 120
Second Line	:
City	:	MOUNT AIRY
State	:	MD
Zip	:	21771-5942
Country	:	US
Telephone Number	:	240-215-6370
Fax Number	:

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

Provider Enumeration Date	:	08/08/2008
Last Update Date	:	04/30/2019

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