1275550279 NPI number — ROY D CHISHOLM III M.D.

Table of content: ROY D CHISHOLM III M.D. (NPI 1275550279)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275550279 NPI number — ROY D CHISHOLM III M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CHISHOLM
Provider First Name:
ROY
Provider Middle Name:
D
Provider Name Prefix Text:
Provider Name Suffix Text:
III
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1275550279
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/13/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12502 WILLOWBROOK RD
Provider Second Line Business Mailing Address:
SUITE 500
Provider Business Mailing Address City Name:
CUMBERLAND
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21502-6491
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
301-724-8847
Provider Business Mailing Address Fax Number:
301-724-7016

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12502 WILLOWBROOK RD
Provider Second Line Business Practice Location Address:
SUITE 500
Provider Business Practice Location Address City Name:
CUMBERLAND
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21502-6491
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-724-8847
Provider Business Practice Location Address Fax Number:
301-724-7016
Provider Enumeration Date:
07/16/2006

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: 208600000X , with the licence number:  D34362 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0126225000 . This is a "WV MEDICAID" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 531441100 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 425241 . This is a "MAMSI" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 1344505 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 424535 . This is a "CAREFIRST BLUE SHIELD" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 2530906005 . This is a "CIGNA" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com