Healthcare Provider Details

I. General information

NPI: 1558349514
Provider Name (Legal Business Name): CHARLES MATTHEW CHELICH D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/09/2006
Last Update Date: 01/08/2024
Certification Date: 01/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16240 PRINCE DR
SOUTH HOLLAND IL
60473-3233
US

IV. Provider business mailing address

71 W 156TH STREET SUITE 305
HARVEY IL
60426-4264
US

V. Phone/Fax

Practice location:
  • Phone: 708-331-0011
  • Fax: 708-331-0008
Mailing address:
  • Phone: 708-331-0011
  • Fax: 815-331-0008

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036078091
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: