Provider Demographics
NPI:1295958569
Name:WALTER D CAMPBELL MD LLC
Entity type:Organization
Organization Name:WALTER D CAMPBELL MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:D
Authorized Official - Last Name:CAMPBELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-724-1940
Mailing Address - Street 1:2401 RAVINE WAY
Mailing Address - Street 2:SUITE 101
Mailing Address - City:GLENVIEW
Mailing Address - State:IL
Mailing Address - Zip Code:60025-7645
Mailing Address - Country:US
Mailing Address - Phone:847-724-1940
Mailing Address - Fax:847-724-1985
Practice Address - Street 1:2401 RAVINE WAY
Practice Address - Street 2:SUITE 101
Practice Address - City:GLENVIEW
Practice Address - State:IL
Practice Address - Zip Code:60025-7645
Practice Address - Country:US
Practice Address - Phone:847-724-1940
Practice Address - Fax:847-724-1985
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-11
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========OtherTAX ID NUMBER