1053469387 NPI number — CHERI W KELLY PA

Table of content: JESLYNN LOVE (NPI 1497309207)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053469387 NPI number — CHERI W KELLY PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KELLY
Provider First Name:
CHERI
Provider Middle Name:
W
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1053469387
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/13/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 577
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CARTERVILLE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62918-0577
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-956-9540
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7 S HOSPITAL DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MURPHYSBORO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62966-3333
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-687-3418
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/05/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363AM0700X , with the licence number:  085001319 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 370966854002 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: CF3444 . This is a "MEDICARE RR" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 370966854005 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 132564 . This is a "HEALTH ALLIANCE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 085001319 . This is a "STATE LICENSE NUMBER" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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