Provider Demographics
NPI:1063429470
Name:CAMPBELL, GLENN A (MD)
Entity type:Individual
Prefix:
First Name:GLENN
Middle Name:A
Last Name:CAMPBELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 S 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-7246
Mailing Address - Country:US
Mailing Address - Phone:601-268-5830
Mailing Address - Fax:601-579-5240
Practice Address - Street 1:4209 LINCOLN ROAD
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402
Practice Address - Country:US
Practice Address - Phone:601-579-5400
Practice Address - Fax:601-261-3521
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2020-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS11345207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
080015084OtherRAILROAD MEDICARE
MS00010478Medicaid
MS1558924OtherAMERICAN ADMIN GROUP
D45000Medicare UPIN
MS080001493Medicare PIN