Provider Demographics
NPI:1386218139
Name:CHISM MEDICAL CLINIC
Entity Type:Organization
Organization Name:CHISM MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROSABELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:CHISM
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:727-202-0777
Mailing Address - Street 1:6166 SEMINOLE BLVD
Mailing Address - Street 2:
Mailing Address - City:SEMINOLE
Mailing Address - State:FL
Mailing Address - Zip Code:33772-6835
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6166 SEMINOLE BLVD
Practice Address - Street 2:
Practice Address - City:SEMINOLE
Practice Address - State:FL
Practice Address - Zip Code:33772-6835
Practice Address - Country:US
Practice Address - Phone:727-202-0777
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-17
Last Update Date:2021-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty