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General NPI Number Information
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NPI Number | 1467685503
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Entity Type | Organization
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Legal Business Name | CHARLES MATT CHELICH LTD
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Dates
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Enumeration Date | 08/24/2009
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Last Update Date | 01/08/2024
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Provider Practice Location Address
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Address Line | 16240 PRINCE DR
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City | SOUTH HOLLAND
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State | IL
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Zip | 60473-3233
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Country | US
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Telephone | 708-331-0011
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Fax | 708-331-0008
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Provider Business Mailing Address
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Address Line | 16240 PRINCE DR
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City | SOUTH HOLLAND
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State | IL
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Zip | 60473-3233
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Country | US
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Telephone | 708-331-0011
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Fax | 708-331-0008
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Authorized Official
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Title or Position | OWNER/PHYSICIAN
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Name | DR. CHARLES MATTHEW CHELICH
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Credential | D.O.
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Telephone | 708-331-0011
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 036078091
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License Number State | IL
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