Provider Demographics
NPI:1891761714
Name:KELLEHER, ROBERT P (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:P
Last Name:KELLEHER
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 1:521 MOUNT AUBURN ST
Mailing Address - Street 2:STE 202
Mailing Address - City:WATERTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02472-4191
Mailing Address - Country:US
Mailing Address - Phone:617-926-9000
Mailing Address - Fax:617-926-7053
Practice Address - Street 1:521 MOUNT AUBURN ST
Practice Address - Street 2:STE 202
Practice Address - City:WATERTOWN
Practice Address - State:MA
Practice Address - Zip Code:02472-4191
Practice Address - Country:US
Practice Address - Phone:617-926-9000
Practice Address - Fax:617-926-7053
Is Sole Proprietor?:No
Enumeration Date:2006-02-28
Last Update Date:2010-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA227042207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2115620Medicaid
MAJ40520OtherBLUE CROSS
MAJ40520OtherBLUE CROSS