Healthcare Provider Details

I. General information

NPI: 1700096005
Provider Name (Legal Business Name): CHISHOLM BRUCE B MC ASC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

39300 BOB HOPE DR BANNAN BLDG 1208
RANCHO MIRAGE CA
92270-3203
US

IV. Provider business mailing address

39300 BOB HOPE DR BANNAN BLDG 1208
RANCHO MIRAGE CA
92270-3203
US

V. Phone/Fax

Practice location:
  • Phone: 760-779-9559
  • Fax: 760-779-5077
Mailing address:
  • Phone: 760-779-9559
  • Fax: 760-779-5077

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License NumberG81937
License Number StateCA

VIII. Authorized Official

Name: DR. BRUCE B CHISHOLM
Title or Position: CEO
Credential: MD
Phone: 760-779-9559