Provider Demographics
NPI:1306910047
Name:DEWITT AND CHISOLM, LLC
Entity type:Organization
Organization Name:DEWITT AND CHISOLM, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:HENRY
Authorized Official - Middle Name:L
Authorized Official - Last Name:DEWITT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:706-208-1408
Mailing Address - Street 1:1500 OGLETHORPE AVE
Mailing Address - Street 2:SUITE 3300
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30606-2179
Mailing Address - Country:US
Mailing Address - Phone:706-208-1408
Mailing Address - Fax:706-208-1407
Practice Address - Street 1:1500 OGLETHORPE AVE
Practice Address - Street 2:SUITE 3300
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-2179
Practice Address - Country:US
Practice Address - Phone:706-208-1408
Practice Address - Fax:706-208-1407
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA055115207Q00000X
GA027533207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA08BBQGDMedicare ID - Type Unspecified
GA08BBRDGMedicare ID - Type Unspecified