Basic Information
| Provider Information | |||||||||
| NPI: | 1366731150 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHISHOLM | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | VALENTINE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | III | ||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5 NEPONSET ST | ||||||||
| Address2: | |||||||||
| City: | WORCESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 016062714 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5085952300 | ||||||||
| FaxNumber: | 5088535226 | ||||||||
| Practice Location | |||||||||
| Address1: | 5 NEPONSET ST | ||||||||
| Address2: | |||||||||
| City: | WORCESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 01606 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5085952300 | ||||||||
| FaxNumber: | 5088535226 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/01/2011 | ||||||||
| LastUpdateDate: | 01/04/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 042-0012873 | VT | N | Allopathic & Osteopathic Physicians | Family Medicine | 207QA0401X | 277524 | MA | Y | Allopathic & Osteopathic Physicians | Family Medicine | Addiction Medicine |
No ID Information.