Provider Demographics
NPI:1033269303
Name:CHELLY, MARJORIE R (MD)
Entity Type:Individual
Prefix:
First Name:MARJORIE
Middle Name:R
Last Name:CHELLY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1512 W KIRBY PL
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71103-3822
Mailing Address - Country:US
Mailing Address - Phone:318-675-7636
Mailing Address - Fax:
Practice Address - Street 1:1501 KINGS HWY
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103-4228
Practice Address - Country:US
Practice Address - Phone:318-675-5000
Practice Address - Fax:318-675-5666
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2013-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN3553208200000X
LA2059912086S0105X, 207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
No2086S0105XAllopathic & Osteopathic PhysiciansSurgerySurgery of the Hand
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX2324209Medicaid
LA276655YH54OtherMEDICARE - PTAN