=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427291061
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ADRIATIK KELLICI MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/13/2009
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 38582 HERITAGE CT
-----------------------------------------------------
City | WILLOUGHBY
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44094-8839
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 216-375-7303
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 38582 HERITAGE CT
-----------------------------------------------------
City | WILLOUGHBY
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44094
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 216-375-7303
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 35094153
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------