Provider Demographics
NPI:1205895679
Name:CHISOM MEDICAL GROUP LLC.
Entity type:Organization
Organization Name:CHISOM MEDICAL GROUP LLC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:SYLVESTER
Authorized Official - Middle Name:CHUKWUEMEKA
Authorized Official - Last Name:OGUH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-454-3878
Mailing Address - Street 1:129 E MCDOWELL RD
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39204-5719
Mailing Address - Country:US
Mailing Address - Phone:601-376-0855
Mailing Address - Fax:601-376-0854
Practice Address - Street 1:129 E MCDOWELL RD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39204-5719
Practice Address - Country:US
Practice Address - Phone:601-376-0855
Practice Address - Fax:601-376-0854
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS06365 / 11.1332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00172074Medicaid
MS00172074Medicaid
MS4576870001Medicare ID - Type UnspecifiedMEDICARE