Healthcare Provider Details

I. General information

NPI: 1871507632
Provider Name (Legal Business Name): CHISHOLM MEDICAL CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2006
Last Update Date: 04/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 1ST AVE SW SUITE 1
CHISHOLM MN
55719-2081
US

IV. Provider business mailing address

3920 13TH AVE E SUITE 6
HIBBING MN
55746-3675
US

V. Phone/Fax

Practice location:
  • Phone: 218-254-7476
  • Fax:
Mailing address:
  • Phone: 218-263-7540
  • Fax: 866-732-0699

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. WILLIAM WILSON
Title or Position: OWNER
Credential: MD
Phone: 218-254-7476