Provider Demographics
NPI:1336685908
Name:CAMELOT FAMILY HEALTH LLC
Entity Type:Organization
Organization Name:CAMELOT FAMILY HEALTH LLC
Other - Org Name:DR DAVID CHISHOLM
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:R
Authorized Official - Last Name:CHISHOLM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:907-357-6180
Mailing Address - Street 1:500 E SWANSON AVE
Mailing Address - Street 2:STE 3
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-7197
Mailing Address - Country:US
Mailing Address - Phone:907-357-6180
Mailing Address - Fax:907-357-6184
Practice Address - Street 1:500 E SWANSON AVE
Practice Address - Street 2:STE 3
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-7197
Practice Address - Country:US
Practice Address - Phone:907-357-6180
Practice Address - Fax:907-357-6184
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-06
Last Update Date:2017-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1009915Medicaid