Provider Demographics
NPI:1891787172
Name:KELLEHER, ROBERT M (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:M
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 1:875 JOHNSON FERRY RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342
Mailing Address - Country:US
Mailing Address - Phone:404-257-9933
Mailing Address - Fax:404-257-9931
Practice Address - Street 1:875 JOHNSON FERRY RD
Practice Address - Street 2:SUITE 300
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342
Practice Address - Country:US
Practice Address - Phone:404-257-9933
Practice Address - Fax:404-257-9931
Is Sole Proprietor?:No
Enumeration Date:2005-08-22
Last Update Date:2015-10-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA012223174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAD45821Medicare UPIN
GA07BBSQNMedicare ID - Type Unspecified