Provider Demographics
NPI:1417185984
Name:ELOSIEBO, MECHELLE E (MD)
Entity Type:Individual
Prefix:DR
First Name:MECHELLE
Middle Name:E
Last Name:ELOSIEBO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3 SAINT ELIZABETH BLVD STE 4000
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269-1284
Mailing Address - Country:US
Mailing Address - Phone:618-233-5480
Mailing Address - Fax:618-222-4790
Practice Address - Street 1:3 SAINT ELIZABETH BLVD STE 4000
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269-1284
Practice Address - Country:US
Practice Address - Phone:618-233-5480
Practice Address - Fax:618-222-4790
Is Sole Proprietor?:No
Enumeration Date:2009-06-23
Last Update Date:2018-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL036142813207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program