Provider Demographics
NPI:1992706113
Name:CHISHOLM, PATRICIA A (MD)
Entity type:Individual
Prefix:
First Name:PATRICIA
Middle Name:A
Last Name:CHISHOLM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:PATRICIA
Other - Middle Name:ANN
Other - Last Name:WATCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:P.O. BOX 405827
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-5827
Mailing Address - Country:US
Mailing Address - Phone:901-227-4068
Mailing Address - Fax:870-934-5384
Practice Address - Street 1:6027 WALNUT GROVE
Practice Address - Street 2:SUITE 110
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38120
Practice Address - Country:US
Practice Address - Phone:901-226-3520
Practice Address - Fax:901-226-2012
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2012-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN39713207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN33366301Medicaid
TN103I083480Medicare PIN
TN33366301Medicaid
H95045Medicare UPIN
TN3873609Medicare ID - Type Unspecified