Provider Demographics
NPI:1972172575
Name:CAMPBELL, EDWARD C
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:C
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 1:4450 MOBILE DR APT 217
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43220-3737
Mailing Address - Country:US
Mailing Address - Phone:614-902-5380
Mailing Address - Fax:
Practice Address - Street 1:4450 MOBILE DR APT 217
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43220-3737
Practice Address - Country:US
Practice Address - Phone:614-902-5380
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-18
Last Update Date:2021-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH602360230621376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH602360230621Medicaid