Basic Information
Provider Information | |||||||||
NPI: | 1972952562 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ELWOOD | ||||||||
FirstName: | CHELSEA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2723 S 7TH ST STE A | ||||||||
Address2: |   | ||||||||
City: | TERRE HAUTE | ||||||||
State: | IN | ||||||||
PostalCode: | 478023558 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8122381730 | ||||||||
FaxNumber: | 8122421565 | ||||||||
Practice Location | |||||||||
Address1: | 1530 N 7TH ST STE 109 | ||||||||
Address2: |   | ||||||||
City: | TERRE HAUTE | ||||||||
State: | IN | ||||||||
PostalCode: | 47807 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8122429631 | ||||||||
FaxNumber: | 8122429647 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/06/2016 | ||||||||
LastUpdateDate: | 01/07/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 10002063A | IN | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
ID | Type | State | Issuer | Description | 300005224 | 05 | IN |   | MEDICAID |