Provider Demographics
NPI:1518185982
Name:KELLEHER, PETER M (MD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:M
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 1:536 COTTONWOOD RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59718
Mailing Address - Country:US
Mailing Address - Phone:406-586-8029
Mailing Address - Fax:406-586-8009
Practice Address - Street 1:536 COTTONWOOD RD
Practice Address - Street 2:SUITE 100
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59718
Practice Address - Country:US
Practice Address - Phone:406-586-8029
Practice Address - Fax:406-586-8009
Is Sole Proprietor?:No
Enumeration Date:2007-04-23
Last Update Date:2011-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT11795207XX0005X
PAMD431276207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0000093258OtherBCBS OF MONTANA