Provider Demographics
NPI:1194748186
Name:CAMPBELL, MICHAEL ROY (ATC)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ROY
Last Name:CAMPBELL
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6025 RISING FAWN CT
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:IN
Mailing Address - Zip Code:47122-8767
Mailing Address - Country:US
Mailing Address - Phone:812-951-3317
Mailing Address - Fax:
Practice Address - Street 1:215 CENTRAL AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40208-1418
Practice Address - Country:US
Practice Address - Phone:502-587-4991
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYAT3852255A2300X
IN36000596A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer