Provider Demographics
NPI:1578651741
Name:CAMPBELL, TIMOTHY JAMES (CRNA)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:JAMES
Last Name:CAMPBELL
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 S MEADOWHILL LN
Mailing Address - Street 2:
Mailing Address - City:MAHOMET
Mailing Address - State:IL
Mailing Address - Zip Code:61853-8521
Mailing Address - Country:US
Mailing Address - Phone:217-586-2564
Mailing Address - Fax:
Practice Address - Street 1:7988 W COUNTY ROAD 350 N
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:IN
Practice Address - Zip Code:47272-9783
Practice Address - Country:US
Practice Address - Phone:217-841-4500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28132356A367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered