Provider Demographics
NPI:1467685503
Name:CHARLES MATT CHELICH LTD
Entity Type:Organization
Organization Name:CHARLES MATT CHELICH LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:MATTHEW
Authorized Official - Last Name:CHELICH
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:708-331-0011
Mailing Address - Street 1:16240 PRINCE DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH HOLLAND
Mailing Address - State:IL
Mailing Address - Zip Code:60473-3233
Mailing Address - Country:US
Mailing Address - Phone:708-331-0011
Mailing Address - Fax:708-331-0008
Practice Address - Street 1:16240 PRINCE DR
Practice Address - Street 2:
Practice Address - City:SOUTH HOLLAND
Practice Address - State:IL
Practice Address - Zip Code:60473-3233
Practice Address - Country:US
Practice Address - Phone:708-331-0011
Practice Address - Fax:708-331-0008
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-24
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036078091207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL902220Medicare PIN