Provider Demographics
NPI:1326052473
Name:KELLEHER, PAUL MITCHELL (DO)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:MITCHELL
Last Name:KELLEHER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:49 W RAYBURN RD
Mailing Address - Street 2:
Mailing Address - City:MILLINGTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07946-1502
Mailing Address - Country:US
Mailing Address - Phone:908-542-1792
Mailing Address - Fax:
Practice Address - Street 1:49 W RAYBURN RD
Practice Address - Street 2:
Practice Address - City:MILLINGTON
Practice Address - State:NJ
Practice Address - Zip Code:07946-1502
Practice Address - Country:US
Practice Address - Phone:908-542-1792
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2015-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB06963200208100000X
NY206597208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02057174Medicaid
NJ029896Medicare PIN
NY02057174Medicaid
NY29Z722Medicare PIN