Provider Demographics
NPI:1558824912
Name:CHISHOLM, AVERY CAMILLE
Entity Type:Individual
Prefix:
First Name:AVERY
Middle Name:CAMILLE
Last Name:CHISHOLM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:273 LANDING DR
Mailing Address - Street 2:
Mailing Address - City:KINGSLAND
Mailing Address - State:GA
Mailing Address - Zip Code:31548-3439
Mailing Address - Country:US
Mailing Address - Phone:904-504-8195
Mailing Address - Fax:
Practice Address - Street 1:MUSC GME OFFICE 169 ASHLEY AVENUE ROOM 202 MUH MSC 33
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29425-0001
Practice Address - Country:US
Practice Address - Phone:843-792-2575
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-11
Last Update Date:2019-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program