Healthcare Provider Details

I. General information

NPI: 1164520375
Provider Name (Legal Business Name): KEITH GREGORY CHISHOLM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 05/28/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10751 MAPLE CREEK DR SUITE 103
TRINITY FL
34655-4418
US

IV. Provider business mailing address

3152 LITTLE RD SUITE 311
TRINITY FL
34655-1864
US

V. Phone/Fax

Practice location:
  • Phone: 727-372-0400
  • Fax: 727-372-0403
Mailing address:
  • Phone: 727-372-0400
  • Fax: 727-372-0403

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberME83998
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: