Provider Demographics
NPI:1619141462
Name:MICHAEL W CLISHAM DPM
Entity Type:Organization
Organization Name:MICHAEL W CLISHAM DPM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PODIATRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:CLISHAM
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:443-460-0127
Mailing Address - Street 1:6304 KENWOOD AVE
Mailing Address - Street 2:3
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21237
Mailing Address - Country:US
Mailing Address - Phone:443-460-0127
Mailing Address - Fax:410-866-6610
Practice Address - Street 1:6304 KENWOOD AVE
Practice Address - Street 2:3
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21237
Practice Address - Country:US
Practice Address - Phone:443-460-0127
Practice Address - Fax:410-866-6610
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-14
Last Update Date:2008-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD00506213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD786108700Medicaid
MD1122910001Medicare NSC
MD786108700Medicaid
T027Medicare PIN