Basic Information
| Provider Information | |||||||||
| NPI: | 1073594719 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHELUCCI | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | M. | ||||||||
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| Credential: | MDF | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2200 JEFFERSON AVE | ||||||||
| Address2: | 4TH FLOOR | ||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436241120 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192512673 | ||||||||
| FaxNumber: | 4192510916 | ||||||||
| Practice Location | |||||||||
| Address1: | 3404 W SYLVANIA AVE | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436234467 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4194072663 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/09/2005 | ||||||||
| LastUpdateDate: | 11/23/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 35046162 | OH | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0538538 | 05 | OH | MEDICAID |