Provider Demographics
NPI:1851475800
Name:KELLEHER, MICHAEL B (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:B
Last Name:KELLEHER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4939 BRITTONFIELD PKWY STE 209
Mailing Address - Street 2:EAST SYRACUSE
Mailing Address - City:EAST SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13057-9208
Mailing Address - Country:US
Mailing Address - Phone:315-218-0085
Mailing Address - Fax:315-218-0087
Practice Address - Street 1:4939 BRITTONFIELD PKWY
Practice Address - Street 2:209
Practice Address - City:EAST SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13057-9208
Practice Address - Country:US
Practice Address - Phone:315-218-0085
Practice Address - Fax:315-218-0087
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2013-03-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY196028207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYG99881Medicare UPIN
NY0232ASMedicare ID - Type Unspecified