Provider Demographics
NPI:1407047459
Name:CHISUM-PRICE, AMANDA G (MD)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:G
Last Name:CHISUM-PRICE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 402330
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-2330
Mailing Address - Country:US
Mailing Address - Phone:479-709-7399
Mailing Address - Fax:479-709-7053
Practice Address - Street 1:923 LEXINGTON AVE
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72901-4943
Practice Address - Country:US
Practice Address - Phone:479-709-7350
Practice Address - Fax:479-709-7355
Is Sole Proprietor?:No
Enumeration Date:2007-08-06
Last Update Date:2012-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-5310208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR166054001Medicaid
OK200117300AMedicaid
AR166054001Medicaid