Basic Information
| Provider Information | |||||||||
| NPI: | 1982661567 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KELSEY | ||||||||
| FirstName: | SEKOU | ||||||||
| MiddleName: | KHARY | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1414 CROSS ST STE 240 | ||||||||
| Address2: | |||||||||
| City: | SHILOH | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622692988 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182342390 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1414 CROSS ST STE 240 | ||||||||
| Address2: | |||||||||
| City: | SHILOH | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622692988 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182342390 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/27/2006 | ||||||||
| LastUpdateDate: | 04/02/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 036109572 | IL | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 1982661567 | 05 | IL | MEDICAID |