Provider Demographics
NPI:1598754566
Name:CAMPBELL, GREGORY S (MD)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:S
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:PO BOX 843966
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64184-3966
Mailing Address - Country:US
Mailing Address - Phone:573-884-3300
Mailing Address - Fax:573-884-0943
Practice Address - Street 1:525 N KEENE ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201
Practice Address - Country:US
Practice Address - Phone:573-882-7903
Practice Address - Fax:573-884-4607
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-20
Last Update Date:2019-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR1J31207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO106567OtherBLUE CROSS/BLUE SHIELD
MO203063706Medicaid
MOE92965Medicare UPIN
MO000000896Medicare PIN