Provider Demographics
NPI:1437193828
Name:KELLIS, AUGUSTINE J (MD)
Entity Type:Individual
Prefix:DR
First Name:AUGUSTINE
Middle Name:J
Last Name:KELLIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 7TH AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CHARDON
Mailing Address - State:OH
Mailing Address - Zip Code:44024-2908
Mailing Address - Country:US
Mailing Address - Phone:440-285-2020
Mailing Address - Fax:
Practice Address - Street 1:150 7TH AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:CHARDON
Practice Address - State:OH
Practice Address - Zip Code:44024-2908
Practice Address - Country:US
Practice Address - Phone:440-285-2020
Practice Address - Fax:440-285-8448
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2022-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35060480207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0978036Medicaid
OH180020602OtherRAILROAD MEDICARE
OH0728537Medicare PIN
OH0969300001Medicare NSC
OH0728536Medicare PIN
OH0978036Medicaid