Healthcare Provider Details

I. General information

NPI: 1982661567
Provider Name (Legal Business Name): SEKOU KHARY KELSEY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2006
Last Update Date: 04/02/2021
Certification Date: 03/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1414 CROSS ST STE 240
SHILOH IL
62269-2988
US

IV. Provider business mailing address

1414 CROSS ST STE 240
SHILOH IL
62269-2988
US

V. Phone/Fax

Practice location:
  • Phone: 618-234-2390
  • Fax:
Mailing address:
  • Phone: 618-234-2390
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number036109572
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: