Provider Demographics
NPI:1124084876
Name:CAMPBELL, PENELOPE ANNE (MD)
Entity type:Individual
Prefix:DR
First Name:PENELOPE
Middle Name:ANNE
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:PENELOPE
Other - Middle Name:ANNE
Other - Last Name:THOMPSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 50760
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29579-0013
Mailing Address - Country:US
Mailing Address - Phone:843-903-4111
Mailing Address - Fax:843-903-4242
Practice Address - Street 1:4022 POSTAL WAY STE C
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29579-3537
Practice Address - Country:US
Practice Address - Phone:843-903-4111
Practice Address - Fax:843-903-4242
Is Sole Proprietor?:No
Enumeration Date:2006-04-21
Last Update Date:2012-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC273492080A0000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC7844OtherMEDICARE PTAN
SC570783896OtherFED TAX ID
SCGP4505Medicaid