1891732103 NPI number — MRS. SUPORIOR R HARRIS-CAMPBELL DNP

Table of content: MRS. SUPORIOR R HARRIS-CAMPBELL DNP (NPI 1891732103)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891732103 NPI number — MRS. SUPORIOR R HARRIS-CAMPBELL DNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HARRIS-CAMPBELL
Provider First Name:
SUPORIOR
Provider Middle Name:
R
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
DNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HARRIS
Provider Other First Name:
SUPORIOR
Provider Other Middle Name:
R
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
II
Provider Other Credential Text:
DNP
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1891732103
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/08/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12125 WOODCREST EXECUTIVE DR
Provider Second Line Business Mailing Address:
SUITE 220
Provider Business Mailing Address City Name:
SAINT LOUIS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63141-5001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-317-0600
Provider Business Mailing Address Fax Number:
314-317-0606

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5 MOBILE INFIRMARY CIR
Provider Second Line Business Practice Location Address:
POB SUITE 308
Provider Business Practice Location Address City Name:
MOBILE
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36607-3513
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
251-435-7223
Provider Business Practice Location Address Fax Number:
251-435-7282
Provider Enumeration Date:
06/02/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363L00000X , with the licence number:  1063773 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: 1063773 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 133128 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".




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