Provider Demographics
NPI:1417046004
Name:KELLEHER, MICHAEL JOHN (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JOHN
Last Name:KELLEHER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 MILFORD STREET
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SALISBURY
Mailing Address - State:MD
Mailing Address - Zip Code:21804
Mailing Address - Country:US
Mailing Address - Phone:410-742-1567
Mailing Address - Fax:410-742-1906
Practice Address - Street 1:106 MILFORD STREET
Practice Address - Street 2:SUITE 101
Practice Address - City:SALISBURY
Practice Address - State:MD
Practice Address - Zip Code:21804
Practice Address - Country:US
Practice Address - Phone:410-742-1567
Practice Address - Fax:410-742-1906
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2010-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD40516207Y00000X, 207YX0602X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No207YX0602XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngic Allergy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD091591200Medicaid
MD091591200Medicaid
E64825Medicare UPIN