Provider Demographics
NPI:1871831669
Name:PAUL MITCHELL KELLEHER DO LLC
Entity Type:Organization
Organization Name:PAUL MITCHELL KELLEHER DO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:MITCHELL
Authorized Official - Last Name:KELLEHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:908-647-1148
Mailing Address - Street 1:49 W RAYBURN RD
Mailing Address - Street 2:
Mailing Address - City:MILLINGTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07946-1502
Mailing Address - Country:US
Mailing Address - Phone:908-542-1792
Mailing Address - Fax:
Practice Address - Street 1:49 W RAYBURN RD
Practice Address - Street 2:
Practice Address - City:MILLINGTON
Practice Address - State:NJ
Practice Address - Zip Code:07946-1502
Practice Address - Country:US
Practice Address - Phone:908-542-1792
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-29
Last Update Date:2015-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMB069632208100000X
NY206597208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02057174Medicaid
NY29Z722Medicare PIN
NJ279920Medicare PIN
NY02057174Medicaid