Provider Demographics
NPI:1053469387
Name:KELLY, CHERI W (PA)
Entity Type:Individual
Prefix:
First Name:CHERI
Middle Name:W
Last Name:KELLY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 577
Mailing Address - Street 2:
Mailing Address - City:CARTERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62918-0577
Mailing Address - Country:US
Mailing Address - Phone:618-956-9540
Mailing Address - Fax:
Practice Address - Street 1:7 S HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:MURPHYSBORO
Practice Address - State:IL
Practice Address - Zip Code:62966-3333
Practice Address - Country:US
Practice Address - Phone:618-687-3418
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-05
Last Update Date:2012-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085001319363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL370966854002Medicaid
ILCF3444OtherMEDICARE RR
IL370966854005Medicaid
IL132564OtherHEALTH ALLIANCE
IL085001319OtherSTATE LICENSE NUMBER
ILS97504Medicare UPIN
ILCF3444OtherMEDICARE RR
IL640701Medicare Oscar/Certification
IL141848Medicare Oscar/Certification