Basic Information
| Provider Information | |||||||||
| NPI: | 1326001272 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KELLEHER | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | S. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2085 ROSWELL RD | ||||||||
| Address2: | APT 1734 | ||||||||
| City: | MARIETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300627517 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7704246893 | ||||||||
| FaxNumber: | 6788190357 | ||||||||
| Practice Location | |||||||||
| Address1: | 55 WHITCHER ST NE | ||||||||
| Address2: | SUITE 350 | ||||||||
| City: | MARIETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300601155 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7704246893 | ||||||||
| FaxNumber: | 6788190357 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 004757 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.