Healthcare Provider Details

I. General information

NPI: 1700159548
Provider Name (Legal Business Name): BRUCE B CHISHOLM MD A PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/09/2012
Last Update Date: 02/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

39300 BOB HOPE DR BANNAN BLDG SUITE 1208
RANCHO MIRAGE CA
92270-7088
US

IV. Provider business mailing address

39300 BOB HOPE DR BANNAN BLDG SUITE 1208
RANCHO MIRAGE CA
92270-7088
US

V. Phone/Fax

Practice location:
  • Phone: 760-779-9559
  • Fax:
Mailing address:
  • Phone: 760-779-9559
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberG81937
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License NumberG81937
License Number StateCA

VIII. Authorized Official

Name: BRUCE B CHISHOLM
Title or Position: PRESIDENT
Credential: M.D.
Phone: 760-779-9559