Healthcare Provider Details

I. General information

NPI: 1366482507
Provider Name (Legal Business Name): NEWTON W CHISM JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/07/2006
Last Update Date: 02/01/2021
Certification Date: 02/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 BELLEVUE RD #23 ERIN OFFICE PARK
DUBLIN GA
31021-2885
US

IV. Provider business mailing address

2400 BELLEVUE RD STE 23
DUBLIN GA
31021-2888
US

V. Phone/Fax

Practice location:
  • Phone: 478-272-8580
  • Fax: 478-275-0012
Mailing address:
  • Phone: 478-272-8580
  • Fax: 478-275-0012

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number017442
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number017442
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: