Basic Information
| Provider Information | |||||||||
| NPI: | 1053469387 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KELLY | ||||||||
| FirstName: | CHERI | ||||||||
| MiddleName: | W | ||||||||
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| NameSuffix: | |||||||||
| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 577 | ||||||||
| Address2: | |||||||||
| City: | CARTERVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 629180577 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6189569540 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 7 S HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | MURPHYSBORO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 629663333 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6186873418 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/05/2007 | ||||||||
| LastUpdateDate: | 09/13/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 085001319 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 370966854002 | 05 | IL | MEDICAID | CF3444 | 01 | IL | MEDICARE RR | OTHER | 370966854005 | 05 | IL | MEDICAID | 132564 | 01 | IL | HEALTH ALLIANCE | OTHER | 085001319 | 01 | IL | STATE LICENSE NUMBER | OTHER |