MEDICARE: FAITH PAULINE CHISUM MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	A98040	CA

General Provider Information

NPI Number	:	1346432069
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	FAITH PAULINE CHISUM MD

Provider Business Mailing Address
First Line	:	949 PALM AVE
Second Line	:
City	:	IMPERIAL BEACH
State	:	CA
Zip	:	91932-1503
Country	:	US
Telephone Number	:	619-429-3733
Fax Number	:	619-429-3823

Provider Business Practice Location Address
First Line	:	949 PALM AVE
Second Line	:
City	:	IMPERIAL BEACH
State	:	CA
Zip	:	91932-1503
Country	:	US
Telephone Number	:	619-429-3733
Fax Number	:	619-429-3823

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/16/2007
Last Update Date	:	08/27/2008

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