MEDICARE: MR. TELLY R SHELTON SR.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	347C00000X	Private Vehicle	S43581676353	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1811373418	OTHER	IL	MEDICAL PROVIDER

General Provider Information

NPI Number	:	1811373418
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. TELLY R SHELTON SR.

Provider Business Mailing Address
First Line	:	7810 S EUCLID AVE
Second Line	:	2S
City	:	CHICAGO
State	:	IL
Zip	:	60649
Country	:	US
Telephone Number	:	708-502-3718
Fax Number	:

Provider Business Practice Location Address
First Line	:	7810 S EUCLID AVE
Second Line	:	2S
City	:	CHICAGO
State	:	IL
Zip	:	60649-4626
Country	:	US
Telephone Number	:	708-502-3718
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/05/2015
Last Update Date	:	11/09/2015

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