1780114710 NPI number — MRS. KELLY FISCHER CELEK PA-C

Table of content: MRS. KELLY FISCHER CELEK PA-C (NPI 1780114710)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780114710 NPI number — MRS. KELLY FISCHER CELEK PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CELEK
Provider First Name:
KELLY
Provider Middle Name:
FISCHER
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
FISCHER
Provider Other First Name:
KELLY
Provider Other Middle Name:
LYNN
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA-C
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1780114710
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/04/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 751461
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHARLOTTE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28275-1461
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
843-792-6200
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
316 CALHOUN STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHARLESTON
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29401-1113
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-724-2010
Provider Business Practice Location Address Fax Number:
843-724-2005
Provider Enumeration Date:
06/13/2017

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: 363A00000X , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: 2770 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 3071PA , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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