Provider Demographics
NPI:1851577837
Name:CAMPBELL, MATTHEW NOAH (PT)
Entity type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:NOAH
Last Name:CAMPBELL
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33900 HARPER AVE STE 104
Mailing Address - Street 2:
Mailing Address - City:CLINTON TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48035-4258
Mailing Address - Country:US
Mailing Address - Phone:586-350-2644
Mailing Address - Fax:586-541-3735
Practice Address - Street 1:12955 OLD MERIDIAN ST STE 101
Practice Address - Street 2:
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46032
Practice Address - Country:US
Practice Address - Phone:317-819-6600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-21
Last Update Date:2018-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05009428A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201002990Medicaid
898310IIIMedicare PIN