Provider Demographics
NPI:1275550279
Name:CHISHOLM, ROY D III (MD)
Entity Type:Individual
Prefix:
First Name:ROY
Middle Name:D
Last Name:CHISHOLM
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:12502 WILLOWBROOK RD
Mailing Address - Street 2:SUITE 500
Mailing Address - City:CUMBERLAND
Mailing Address - State:MD
Mailing Address - Zip Code:21502-6491
Mailing Address - Country:US
Mailing Address - Phone:301-724-8847
Mailing Address - Fax:301-724-7016
Practice Address - Street 1:12502 WILLOWBROOK RD
Practice Address - Street 2:SUITE 500
Practice Address - City:CUMBERLAND
Practice Address - State:MD
Practice Address - Zip Code:21502-6491
Practice Address - Country:US
Practice Address - Phone:301-724-8847
Practice Address - Fax:301-724-7016
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-16
Last Update Date:2024-03-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MDD34362208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0126225000OtherWV MEDICAID
MD531441100Medicaid
MD425241OtherMAMSI
MD1344505OtherUNITED HEALTHCARE
MD424535OtherCAREFIRST BLUE SHIELD
MD2530906005OtherCIGNA
MD2530906005OtherCIGNA
MD1344505OtherUNITED HEALTHCARE