Provider Demographics
NPI:1154891877
Name:CAMPBELL, MICHAEL ANDREW WADE
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:ANDREW WADE
Last Name:CAMPBELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4550 AMYSAYE WALK NW
Mailing Address - Street 2:
Mailing Address - City:ACWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:30101-8342
Mailing Address - Country:US
Mailing Address - Phone:404-917-7992
Mailing Address - Fax:
Practice Address - Street 1:4550 AMYSAYE WALK NW
Practice Address - Street 2:
Practice Address - City:ACWORTH
Practice Address - State:GA
Practice Address - Zip Code:30101-8342
Practice Address - Country:US
Practice Address - Phone:404-917-7992
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-26
Last Update Date:2018-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA404144372600000X, 374U00000X, 3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No372600000XNursing Service Related ProvidersAdult Companion
No374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA404144OtherSTATE ISSUE NUMBER