Provider Demographics
NPI:1902998917
Name:CAMPBELL, NICHOLAS (MD)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
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 1027
Mailing Address - Street 2:100 N. OAK
Mailing Address - City:TOWNSEND
Mailing Address - State:MT
Mailing Address - Zip Code:59644-1027
Mailing Address - Country:US
Mailing Address - Phone:406-266-5204
Mailing Address - Fax:406-266-4428
Practice Address - Street 1:100 N OAK ST
Practice Address - Street 2:
Practice Address - City:TOWNSEND
Practice Address - State:MT
Practice Address - Zip Code:59644-2306
Practice Address - Country:US
Practice Address - Phone:406-266-5204
Practice Address - Fax:406-266-4428
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2014-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT4938207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0075004Medicaid
MT0075004Medicaid
MO000024018Medicare ID - Type Unspecified