MEDICARE: DOUGLAS CHISOLM C.R.N.A.

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	367500000X	Certified Registered Nurse Anesthetist	3628861	NY
2	367500000X	Certified Registered Nurse Anesthetist	362886	NY

General Provider Information

NPI Number	:	1811993496
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DOUGLAS CHISOLM C.R.N.A.

Provider Business Mailing Address
First Line	:	575 LEXINGTON AVE
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10022-6102
Country	:	US
Telephone Number	:	212-312-5241
Fax Number	:	212-312-5855

Provider Business Practice Location Address
First Line	:	170 WILLIAM ST
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10038-2612
Country	:	US
Telephone Number	:	212-312-5244
Fax Number	:

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

Provider Enumeration Date	:	06/28/2005
Last Update Date	:	02/13/2025

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Directions to “ DOUGLAS CHISOLM C.R.N.A.” Practice Location

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