Provider Demographics
NPI:1073594719
Name:CHELUCCI, KENNETH M (MDF)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:M
Last Name:CHELUCCI
Suffix:
Gender:M
Credentials:MDF
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2200 JEFFERSON AVE
Mailing Address - Street 2:4TH FLOOR
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43624-1120
Mailing Address - Country:US
Mailing Address - Phone:419-251-2673
Mailing Address - Fax:419-251-0916
Practice Address - Street 1:3404 W SYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43623-4467
Practice Address - Country:US
Practice Address - Phone:419-407-2663
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-09
Last Update Date:2015-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35046162207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0538538Medicaid
OH0538538Medicaid
A80129Medicare UPIN