Provider Demographics
NPI:1508988353
Name:CHELLI, EDWIN S (MD)
Entity Type:Individual
Prefix:DR
First Name:EDWIN
Middle Name:S
Last Name:CHELLI
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 1:9 WISHING WELL CT
Mailing Address - Street 2:
Mailing Address - City:SIMPSONVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29681-4963
Mailing Address - Country:US
Mailing Address - Phone:630-363-5065
Mailing Address - Fax:
Practice Address - Street 1:289 IRELAND AVE
Practice Address - Street 2:
Practice Address - City:FORT KNOX
Practice Address - State:KY
Practice Address - Zip Code:40121-5111
Practice Address - Country:US
Practice Address - Phone:812-526-1135
Practice Address - Fax:812-526-1768
Is Sole Proprietor?:No
Enumeration Date:2007-04-04
Last Update Date:2016-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-111266207Q00000X
MI430-10-72926207Q00000X
SC37525207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine