MEDICARE: MS. DEA DENISE CAMPBELL D.O.

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	108529	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1275538324
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. DEA DENISE CAMPBELL D.O.

Provider Business Mailing Address
First Line	:	417 PARK LN
Second Line	:
City	:	CHILLICOTHEE
State	:	MO
Zip	:	64601-1550
Country	:	US
Telephone Number	:	660-646-3400
Fax Number	:	660-646-3410

Provider Business Practice Location Address
First Line	:	417 PARK LN
Second Line	:
City	:	CHILLICOTHEE
State	:	MO
Zip	:	64601-1550
Country	:	US
Telephone Number	:	660-646-3400
Fax Number	:	660-646-3410

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

Provider Enumeration Date	:	06/16/2005
Last Update Date	:	04/07/2009

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