Basic Information
| Provider Information | |||||||||
| NPI: | 1144253212 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHELLI | ||||||||
| FirstName: | HEPHZIBAH | ||||||||
| MiddleName: | ESTHER | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1015 S HACKETT RD | ||||||||
| Address2: | |||||||||
| City: | WATERLOO | ||||||||
| State: | IA | ||||||||
| PostalCode: | 507013500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3192741000 | ||||||||
| FaxNumber: | 3192926526 | ||||||||
| Practice Location | |||||||||
| Address1: | 555 VALLEY VIEW DR | ||||||||
| Address2: | |||||||||
| City: | MOLINE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 612656138 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3097649675 | ||||||||
| FaxNumber: | 3097643106 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/09/2006 | ||||||||
| LastUpdateDate: | 10/23/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 10/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | R-7957 | IA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 37950 | IA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1144253212 | 05 | IA | MEDICAID | R7957 | 01 | IA | LICENSE NUMBER | OTHER |