Provider Demographics
NPI:1215137880
Name:CHARLES D. CAMPBELL, MD LTD
Entity type:Organization
Organization Name:CHARLES D. CAMPBELL, MD LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:D
Authorized Official - Last Name:CAMPBELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:312-961-9632
Mailing Address - Street 1:357 N CANAL ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60606-1207
Mailing Address - Country:US
Mailing Address - Phone:312-961-9632
Mailing Address - Fax:
Practice Address - Street 1:2525 S MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60616-2333
Practice Address - Country:US
Practice Address - Phone:312-961-9632
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-23
Last Update Date:2010-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036054924208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL3488Medicare PIN