Provider Demographics
NPI:1245516285
Name:CHISHOLM, MICHAEL PHILLIP (DPT)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:PHILLIP
Last Name:CHISHOLM
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4000 EASTERN SKY DR
Mailing Address - Street 2:SUITE 6
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-7351
Mailing Address - Country:US
Mailing Address - Phone:231-932-9014
Mailing Address - Fax:231-932-9034
Practice Address - Street 1:4000 EASTERN SKY DR
Practice Address - Street 2:SUITE 6
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-7351
Practice Address - Country:US
Practice Address - Phone:231-932-9014
Practice Address - Fax:231-932-9034
Is Sole Proprietor?:No
Enumeration Date:2011-10-21
Last Update Date:2012-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501015720225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist