Provider Demographics
NPI:1871507632
Name:CHISHOLM MEDICAL CLINIC
Entity Type:Organization
Organization Name:CHISHOLM MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:218-254-7476
Mailing Address - Street 1:3920 13TH AVE E
Mailing Address - Street 2:SUITE 6
Mailing Address - City:HIBBING
Mailing Address - State:MN
Mailing Address - Zip Code:55746-3675
Mailing Address - Country:US
Mailing Address - Phone:218-263-7540
Mailing Address - Fax:866-732-0699
Practice Address - Street 1:400 1ST AVE SW
Practice Address - Street 2:SUITE 1
Practice Address - City:CHISHOLM
Practice Address - State:MN
Practice Address - Zip Code:55719-2081
Practice Address - Country:US
Practice Address - Phone:218-254-7476
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-28
Last Update Date:2008-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN55A03CHOtherBCBS
MN55A03CHOtherBCBS
MNCH9913Medicare PIN