Healthcare Provider Details

I. General information

NPI: 1245347137
Provider Name (Legal Business Name): ROY ELLIOTT CECCHI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/24/2006
Last Update Date: 02/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

613 DORBETT STREET
JASPER IN
47546
US

IV. Provider business mailing address

613 DORBETT STREET
JASPER IN
47546-2615
US

V. Phone/Fax

Practice location:
  • Phone: 812-634-7123
  • Fax: 812-482-9551
Mailing address:
  • Phone: 812-634-7123
  • Fax: 812-482-3993

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number01041439
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: