Provider Demographics
NPI:1811373418
Name:SHELTON, TELLY R SR
Entity type:Individual
Prefix:MR
First Name:TELLY
Middle Name:R
Last Name:SHELTON
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7810 S EUCLID AVE
Mailing Address - Street 2:2S
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60649
Mailing Address - Country:US
Mailing Address - Phone:708-502-3718
Mailing Address - Fax:
Practice Address - Street 1:7810 S EUCLID AVE
Practice Address - Street 2:2S
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60649-4626
Practice Address - Country:US
Practice Address - Phone:708-502-3718
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-05
Last Update Date:2015-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILS43581676353347C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1811373418OtherMEDICAL PROVIDER