Provider Demographics
NPI:1710910930
Name:KELLEHER, MAUREEN M (MD)
Entity Type:Individual
Prefix:MS
First Name:MAUREEN
Middle Name:M
Last Name:KELLEHER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1355 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:CLIFTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07013-4221
Mailing Address - Country:US
Mailing Address - Phone:973-778-5566
Mailing Address - Fax:973-778-4044
Practice Address - Street 1:1355 BROAD ST
Practice Address - Street 2:
Practice Address - City:CLIFTON
Practice Address - State:NJ
Practice Address - Zip Code:07013-4221
Practice Address - Country:US
Practice Address - Phone:976-377-8556
Practice Address - Fax:973-778-4044
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2014-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME94343207R00000X
PAMD437271207R00000X
NY151662207R00000X
NJ25MA04243300207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ361371BYQMedicare PIN
NYA400035133Medicare PIN
C06994Medicare UPIN
NYW33231Medicare PIN
PA125845Medicare PIN