Provider Demographics
NPI: | 1750499455 |
---|---|
Name: | KANELLAKOS, JAMES G (MD) |
Entity Type: | Individual |
Prefix: | MR |
First Name: | JAMES |
Middle Name: | G |
Last Name: | KANELLAKOS |
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: | 261 JAMES ST |
Mailing Address - Street 2: | SUITE 3F |
Mailing Address - City: | MORRISTOWN |
Mailing Address - State: | NJ |
Mailing Address - Zip Code: | 07960 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 973-538-0029 |
Mailing Address - Fax: | 973-538-4957 |
Practice Address - Street 1: | 261 JAMES ST - 3F |
Practice Address - Street 2: | |
Practice Address - City: | MORRISTOWN |
Practice Address - State: | NJ |
Practice Address - Zip Code: | 07960 |
Practice Address - Country: | US |
Practice Address - Phone: | 973-538-0029 |
Practice Address - Fax: | 973-538-0029 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-08-25 |
Last Update Date: | 2013-02-12 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
NY | 239267 | 207X00000X, 207XX0801X |
NJ | 25MA08242200 | 207X00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207X00000X | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | |
No | 207XX0801X | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Orthopaedic Trauma |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
I52152 | Medicare UPIN | ||
RB0360 | Medicare ID - Type Unspecified |