Basic Information
Provider Information | |||||||||
NPI: | 1033269303 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CHELLY | ||||||||
FirstName: | MARJORIE | ||||||||
MiddleName: | R | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1512 W KIRBY PL | ||||||||
Address2: |   | ||||||||
City: | SHREVEPORT | ||||||||
State: | LA | ||||||||
PostalCode: | 711033822 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3186757636 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1501 KINGS HWY | ||||||||
Address2: |   | ||||||||
City: | SHREVEPORT | ||||||||
State: | LA | ||||||||
PostalCode: | 711034228 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3186755000 | ||||||||
FaxNumber: | 3186755666 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/11/2007 | ||||||||
LastUpdateDate: | 05/21/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208200000X | N3553 | TX | N |   | Allopathic & Osteopathic Physicians | Plastic Surgery |   | 2086S0105X | 205991 | LA | N |   | Allopathic & Osteopathic Physicians | Surgery | Surgery of the Hand | 207X00000X | 205991 | LA | Y |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |   |
ID Information
ID | Type | State | Issuer | Description | 2324209 | 05 | TX |   | MEDICAID | 276655YH54 | 01 | LA | MEDICARE - PTAN | OTHER |