Healthcare Provider Details

I. General information

NPI: 1811993496
Provider Name (Legal Business Name): DOUGLAS CHISOLM C.R.N.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2005
Last Update Date: 02/13/2025
Certification Date: 02/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

170 WILLIAM ST
NEW YORK NY
10038-2612
US

IV. Provider business mailing address

575 LEXINGTON AVE
NEW YORK NY
10022-6102
US

V. Phone/Fax

Practice location:
  • Phone: 212-312-5244
  • Fax:
Mailing address:
  • Phone: 212-312-5241
  • Fax: 212-312-5855

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number3628861
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number362886
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: