Provider Demographics
NPI:1629115126
Name:KANNANKERIL, MARY
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:
Last Name:KANNANKERIL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38 FOX RUN
Mailing Address - Street 2:
Mailing Address - City:NORTH CALDWELL
Mailing Address - State:NJ
Mailing Address - Zip Code:07006-4172
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:170 CHANGEBRIDGE RD
Practice Address - Street 2:BUILDING B3-4
Practice Address - City:MONTVILLE
Practice Address - State:NJ
Practice Address - Zip Code:07045-9115
Practice Address - Country:US
Practice Address - Phone:973-276-0041
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-31
Last Update Date:2013-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA397382084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ456520Medicare ID - Type Unspecified