Provider Demographics
NPI:1891752127
Name:CHISHOLM, GEORGE E (MD)
Entity Type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:E
Last Name:CHISHOLM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:11945 SAN JOSE BLVD
Mailing Address - Street 2:BLDG 300
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32223-1627
Mailing Address - Country:US
Mailing Address - Phone:904-396-1725
Mailing Address - Fax:904-399-1717
Practice Address - Street 1:2 SHIRCLIFF WAY
Practice Address - Street 2:SUITE 500
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32204-4763
Practice Address - Country:US
Practice Address - Phone:904-389-8861
Practice Address - Fax:904-398-0429
Is Sole Proprietor?:No
Enumeration Date:2006-04-28
Last Update Date:2011-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME60786208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL020015741OtherRAILROAD MEDICARE
4311297OtherAETNA
GA000328424DMedicaid
14347OtherBCBS FL
1626415OtherCIGNA
FL270839600Medicaid
208113OtherAVMED
FL270839600Medicaid
GA000328424DMedicaid