Basic Information
| Provider Information | |||||||||
| NPI: | 1811969678 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHALLY | ||||||||
| FirstName: | CECIL | ||||||||
| MiddleName: | H | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 14909 | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554140909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6128711145 | ||||||||
| FaxNumber: | 6128705491 | ||||||||
| Practice Location | |||||||||
| Address1: | 15700 37TH AVE N | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | PLYMOUTH | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554463661 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6128711145 | ||||||||
| FaxNumber: | 6128705491 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/06/2006 | ||||||||
| LastUpdateDate: | 05/21/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | 19040 | MN | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 610577700 | 05 | MN | MEDICAID |